1. The Nature of Errors Richard M. Satava, MD FACS Professor of Surgery University of Washington School of Medicine and Program Manager, Advanced Biomedical Technologies Defense Advanced Research Projects Agency (DARPA) and Special Assistant, Advance Medical Technologies US Army Medical Research and Materiel Command 12 th International Congress European Association for Endoscopic Surgery Barcelona, Spain June 11, 2004 UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE

2. Institute of Medicine Definition of Errors Failure of a planned action to be completed as intended The use of a wrong plan to achieve an aim

3. Patient Safety Foundation Definition of Errors An unintended healthcare outcome caused by a defect in the delivery of care to a patient Health care errors may be of: - Commission (doing the wrong thing) - Omission (not doing the right thing) - Execution (doing the right thing incorrectly) Errors may be made by any member of the health care team in any health care setting

4. Evidence on Surgical Errors Surgical adverse events 1/50 admissions in Colorado and Utah hospitals -1992 Accounted for two-thirds of all adverse events 1 of 8 hospital deaths accounted for by surgical errors

5. Two Major Classes of Errors 1. Systemic A series of errors resulting in an adverse event 2. Specific A specific event which in itself is an error

6. Lucian Leape Classification Diagnostic Errors or delay in diagnosis Failure to employ indicated tests Use of outmoded tests or therapy Failure to act on results of monitoring or testing Treatment Error in performance of an operation, procedure, or test Error in administering treatment Error in dose or method of using a drug Avoidable delay in treatment or response to abnormal test Inappropriate care Preventive Failure to provide prophylactic treatment Inadequate monitoring or follow-up of treatment Other Failure of communication Equipment failure

7. Time of Occurrence Proximate - Those errors which occur before the actual critical event They are not full errors in their own right They can be corrected or “recovered” If unrecognized, compound (“chain of events”) into an error Coface - Those errors that are the direct cause of the adverse event Is the actual event which is identifiable as the “error” If recognized, may/may not allow to be “recovered” If unrecognized, inevitably results in a complication Subsequent - Those errors which occur after the critical event An error which would not have occurred without previous event May/may not be “recovered” Often requires subsequent “remediation” or correction.

8. Do Robots Dream ?