Table 3.
Incidence of human error in adverse events.
| Classification of Human Error | Number (% of cases with AE) |
||
|---|---|---|---|
| Overall | Cranial | Spinal | |
| Total | 270 (25.9) | 141 (26.1) | 129 (25.6) |
| I - Planning or problem solvinga | 58 (5.6) | 36 (6.7) | 22 (4.4) |
| II – Executionb | 191 (18.3) | 92 (17.0) | 99 (19.7) |
| III - Rules violationc | 18 (1.7) | 11 (2.0) | 7 (1.4) |
| IV – Communicationd | 1 (0.1) | 1 (0.2) | 0 (0.0) |
| V – Teamworke | 2 (0.2) | 1 (0.2) | 1 (0.2) |
Incidence of different types of human error in cases with adverse events, classified according to Suliburk and colleagues.
Abbreviation: AE, Adverse Event.
a
includes guideline or protocol misapplications, knowledge deficits, and cognitive bias.
b
includes lack of recognition, lack of attention, memory lapse, and technical errors.
c
includes ignoring routine or cutting corners, optimizing or personal gain, and situational or time pressure.
d
includes absent, assumed and misinterpreted communication.
e
includes ill-defined roles or lack of leadership, lack of group expertise, and failure to evaluate progress.