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Analysis of Human Performance Deficiencies Associated With Surgical Adverse Events

Monday, August 19, 2019

Submitted by


James W. Suliburk, Quentin M. Buck, Chris J. Pirko, Nader N. Massarweh, Neal R. Barshes, Hardeep Singh, Todd K. Rosengart

In a QI study of nearly 5,400 operations, 188 adverse events were recorded.  Of these, over 56% were associated with human error.  Of all human performance deficiencies, cognitive error accounted for over half.

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