Evidence map›Paper›PMID 37381781›Full record

ArticleAnnals of the Royal College of Surgeons of England2024

The application of human reliability analysis to carpal tunnel decompression.

Á Lucey, S Kennedy, A Hussey, N McInerney, J L Kelly, K M Joyce

Abstract read
In one paragraph

Article in Annals of the Royal College of Surgeons of England, 2024. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.

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1 · What the graph read from it

What it found

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2 · The registry

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3 · Its place in the literature

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0 citing papers in PubMed.

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4 · The record

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5 · Who and what money

Authors and funding

6 authors.

Á LuceyGalway University Hospital, Ireland.
S KennedyGalway University Hospital, Ireland.
A HusseyGalway University Hospital, Ireland.
N McInerneyGalway University Hospital, Ireland.
J L KellyGalway University Hospital, Ireland.
K M JoyceGalway University Hospital, Ireland.

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

introductionMany surgical procedures are prone to human error, particularly in the learning phase of skills acquisition. Task standardisation has been suggested as an approach to reducing errors, but it fails to account for the human factors associated with learning. Human reliability analysis (HRA) is a structured approach to assess human error during surgery. This study used HRA methodologies to examine skills acquisition associated with carpal tunnel decompression.

methodsThe individual steps or subtasks required to complete a carpal tunnel decompression were identified using hierarchical task analysis (HTA). The systematic human error reduction and prediction approach (SHERPA) was carried out by consensus of subject matter experts. This identified the potential human errors at each subgoal, the level of risk associated with each task and how these potential errors could be prevented.

resultsCarpal tunnel decompression was broken down into 46 subtasks, of which 21 (45%) were medium risk and 25 (55%) were low risk. Of the 46 subtasks, 4 (9%) were assigned high probability and 18 (39%) were assigned medium probability. High probability errors (>1/50 cases) included selecting incorrect tourniquet size, failure to infiltrate local anaesthetic in a proximal-to-distal direction and completion of the World Health Organization (WHO) surgical sign-out. Three (6%) of the subtasks were assigned high criticality, which included failure to aspirate before anaesthetic injection, whereas 21 (45%) were assigned medium criticality. Remedial strategies for each potential error were devised.

conclusionsThe use of HRA techniques provides surgeons with a platform to identify critical steps that are prone to error. This approach may improve surgical training and enhance patient safety.

Indexed as

Carpal Tunnel SyndromeClinical CompetenceDecompression, SurgicalMedical ErrorsHumansReproducibility of ResultsTask Performance and AnalysisCarpal tunnel decompressionHierarchal task analysisHuman error identificationHuman reliability analysis

Identifiers

PMID37381781
PMCPMC11060861

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.