WTP7.04 Human Factors Analysis of 265 CORESS cases using the NOTSS Framework

Aims Determine the human factors implicated in cases submitted to the Confidential Reporting System in Surgery (CORESS), using the non-technical skills for surgeons (NOTSS) framework. Methods Consecutive cases submitted to CORESS, between 2005 and 2024 were evaluated. This is following on from interim analysis last year. The type of case, whether patient harm occurred, Clavien-Dindo (CD) classification, and the location of the incident were collected. Demographic data was collected but not analysed because they are often changed to protect patient identification. Each case was reviewed according to the non-technical skills for surgeons (NOTSS) taxonomy. Results There were 265 cases included in this final analysis. The most common types of cases were delayed diagnosis (n=44), misuse of equipment or devices (n=36), poor surgical technique (n=26), wrong site surgery (n=16) and known complications (n=14). Two-thirds of patients were harmed, with complications ranging from minor to life-threatening (14 CD I, 26 CD II, 97 CD III, 20 CD IV), and 22 resulting in death (CD V). Incidents occurred most frequently in the operating theatre (n=163), the ward (n=57), or the emergency department (n=19). There were 197 incidents that endangered patient safety related to deficiencies in situational awareness, 157 to poor communication and teamwork, 86 to poor decision-making, and 97 related to leadership failures. Conclusions Human factors are widely implicated in surgical patient safety incidents, including situational awareness, communication and teamwork, and to a lesser extent, decision-making and leadership. Efforts to prevent medical errors should be focused on clinician human factors training.