SETUP OF THE LIGHT CHAIN FOR ELECTIVE LAPAROSCOPIC CHOLECYSTECTOMY: A HUMAN FACTORS ASSESSMENT FOR PATIENT SAFETY pretef@gmail.com

PW03-19

SETUP OF THE LIGHT CHAIN FOR ELECTIVE LAPAROSCOPIC CHOLECYSTECTOMY: A HUMAN FACTORS ASSESSMENT FOR PATIENT SAFETY

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Angela Gurrado angela.gurrado@uniba.it University of Bari Department of Precision and Regenerative Medicine and Jonian area (DiMePRe-J) Bari Italy

Mario Testini mario.testini@uniba.it University of Bari Department of Precision and Regenerative Medicine and Jonian area (DiMePRe-J) Bari Italy

 

 

Italy

Oral or Poster

Human factors are an important concern in the use-related hazards of medical devices, yet little research has been conducted on factors affecting the performance of surgeons using the laparoscopic technology. Elements of a Xenon light chain, commonly used in laparoscopic surgery, may generate extremely high temperatures, capable of causing patient burns and fire ignition. We conducted a proactive error analysis of the process for delivering light from a xenon generator to the tip of the endoscope during laparoscopic cholecystectomy

The process of setup and disassembly of the laparoscopic light chain was decomposed and re-mapped by means of hierarchical task analysis(HTA), combining complementary observations from the surgeons’ and scrub nurses’ perspectives. Systematic human error reduction and prediction analysis(SHERPA) was applied to HTA results. Problems and barriers to the performance of tasks, as factors contributing to errors, were studied by means of work system analysis(Systems Engineering Initiative for Patient Safety-SEIPS), based on data from direct procedural observations and face-to-face interviews with personnel.

SHERPA showed 98 credible errors, two of which bore potentially severe consequences for the patient. Remedy analysis recommended solutions including equipment modification, process redesign, standardization, checklists, and training. Distracting noise emerged from work systems analysis as a commonly perceived problem during the performance of cases.

Error prediction analysis alone often fails to take accurate account of the context in which performance occurs. Pairing SEIPS analysis to SHERPA may offer a more consistent picture of safety hazards in the operating theatre as an adequate basis for a quality improvement initiative