de Leval M R, Carthey J, Wright D J, Farewell V T, Reason J T
Great Ormond Street Hospital for Children NHS Trust, London, UK.
J Thorac Cardiovasc Surg. 2000 Apr;119(4 Pt 1):661-72. doi: 10.1016/S0022-5223(00)70006-7.
To study the role of human factors on surgical outcomes, with a series of 243 arterial switch operations performed by 21 surgeons taken as a model.
The following data were collected: patient-specific and procedural variables, self-assessment questionnaires, and a written report from a human factors researcher who observed the operation. The relationship of patient-specific variables to outcomes (death and death and/or near miss) was used to develop a multivariable baseline model to analyze the role of human factors after adjustment for these variables.
The overall mortality was 6.6% with 24.3% of cases resulting in death and death and/or near misses. The self-assessment questionnaires were found to be unhelpful. Major and minor human failures were extracted from the written report. Major negative events were potentially life-threatening failures, whereas minor events were failures that, in isolation, were not expected to have serious consequences. Major events were closely related to death (P <.001) and death and/or near misses (P <.001). Appropriate compensation, however, sharply reduced the risk of death (P =.003). The total number of minor events was also closely related to both death and death and/or near misses (P <.001).
The study highlights the role of human factors in negative surgical outcomes. Even in the most eventful circumstances, however, appropriate human factors defense mechanisms can lead to a successful outcome.
以21位外科医生实施的243例动脉调转手术为模型，研究人为因素对外科手术结果的影响。
收集以下数据：患者特异性和手术变量、自我评估问卷，以及一位观察手术的人为因素研究人员撰写的书面报告。利用患者特异性变量与结果（死亡以及死亡和/或险些发生不良事件）之间的关系，建立多变量基线模型，以分析在对这些变量进行调整后人为因素的作用。
总体死亡率为6.6%，24.3%的病例导致死亡以及死亡和/或险些发生不良事件。发现自我评估问卷并无帮助。从书面报告中提取重大和轻微人为失误。重大负面事件是潜在危及生命的失误，而轻微事件是单独来看预计不会产生严重后果的失误。重大事件与死亡（P<.001）以及死亡和/或险些发生不良事件（P<.001）密切相关。然而，适当的应对措施大幅降低了死亡风险（P=.003）。轻微事件的总数也与死亡以及死亡和/或险些发生不良事件密切相关（P<.001）。
该研究突出了人为因素在外科手术负面结果中的作用。然而，即使在情况最复杂的情况下，适当的人为因素防御机制也能带来成功的结果。
