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Proceedings Paper

Error analysis in laparoscopic surgery
Author(s): Walter A. Gantert; Frank Tendick; Sunil Bhoyrul; Dana Tyrrell; Yukio Fujino; Shawn Rangel; Marco G. Patti; Lawrence W. Way
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Paper Abstract

Iatrogenic complications in laparoscopic surgery, as in any field, stem from human error. In recent years, cognitive psychologists have developed theories for understanding and analyzing human error, and the application of these principles has decreased error rates in the aviation and nuclear power industries. The purpose of this study was to apply error analysis to laparoscopic surgery and evaluate its potential for preventing complications. Our approach is based on James Reason's framework using a classification of errors according to three performance levels: at the skill- based performance level, slips are caused by attention failures, and lapses result form memory failures. Rule-based mistakes constitute the second level. Knowledge-based mistakes occur at the highest performance level and are caused by shortcomings in conscious processing. These errors committed by the performer 'at the sharp end' occur in typical situations which often times are brought about by already built-in latent system failures. We present a series of case studies in laparoscopic surgery in which errors are classified and the influence of intrinsic failures and extrinsic system flaws are evaluated. Most serious technical errors in lap surgery stem from a rule-based or knowledge- based mistake triggered by cognitive underspecification due to incomplete or illusory visual input information. Error analysis in laparoscopic surgery should be able to improve human performance, and it should detect and help eliminate system flaws. Complication rates in laparoscopic surgery due to technical errors can thus be considerably reduced.

Paper Details

Date Published: 5 June 1998
PDF: 4 pages
Proc. SPIE 3262, Surgical-Assist Systems, (5 June 1998); doi: 10.1117/12.309457
Show Author Affiliations
Walter A. Gantert, Univ. of California/San Francisco (United States)
Frank Tendick, Univ. of California/San Francisco (United States)
Sunil Bhoyrul, Univ. of California/San Francisco (United States)
Dana Tyrrell, Univ. of California/San Francisco (United States)
Yukio Fujino, Univ. of California/San Francisco (United States)
Shawn Rangel, Univ. of California/San Francisco (United States)
Marco G. Patti, Univ. of California/San Francisco (United States)
Lawrence W. Way, Univ. of California/San Francisco (United States)


Published in SPIE Proceedings Vol. 3262:
Surgical-Assist Systems
Roger Von Hanwehr; Marilyn Sue Bogner; Steven T. Charles; Abraham Katzir; Marilyn Sue Bogner; Steven T. Charles; James A. Harrington; Warren S. Grundfest; Louis S. Lome; Warren S. Grundfest; James A. Harrington; Abraham Katzir; Louis S. Lome; Michael W. Vannier; Roger Von Hanwehr, Editor(s)

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