Non-technical Errors, a Hidden Contributor to Patient Mortality in Emergency General Surgery
Jesse D. Ey, Anthony Vo, Victoria Kollias, Octavia Lee, Kelly Hou, Matheesha Herath, John B. North, Martin H. Bruening, Adam J. Wells, Guy J. MaddernObjective:
To characterize the incidence, clinical phase, team responsibility, and behavioral drivers of non-technical errors (NTEs) associated with death in emergency general surgery to inform future NTS improvement strategies.
Background Data:
Deficiencies in surgical non-technical skills (NTS) contribute substantially to patient harm. Emergency general surgery is common, complex, and high-risk, yet characteristics of NTEs remain unknown.
Methods:
Retrospective cohort study including all emergency general surgical mortalities with an adverse event or area of concern from a national, mandated, peer-reviewed mortality audit (2012–2019). Cases were independently assessed by two reviewers using a validated tool to identify and characterize NTEs.
Results:
NTEs occurred in 790/1164 (67.9%) deaths, comprising 1053 unique errors. Situational awareness errors occurred most (518/1053, 49.3%), followed by decision-making errors (431/1053, 40.9%). Most errors arose from few recurring behaviors: for situational awareness, failure to recognize clinical signs (92/518, 17.8%), failure to appreciate illness severity (75/518, 14.5%), and missed diagnosis (73/518, 14.1%); for decision-making, failure to initiate appropriate intervention/investigation (99/431, 23%) or incorrect operation performed (71/431, 16.5%). Error distribution differed significantly (χ²=1325,
Conclusions:
NTEs associated with patient death predominantly occurred outside the operating theatre, arose from few recurrent behaviors, and involved surgical and non-surgical teams. Future NTS improvement strategies must extend beyond the theatre, be behaviorally informed, and target all teams involved.