What are the incidence and causes of human error as a source of adverse events associated with surgical care?

In a quality improvement study including 5365 operations, 188 adverse events were recorded. Of these, 106 adverse events (56.4%) were due to human error, of which cognitive error accounted for 99 of 192 human performance deficiencies (51.6%).

Current systems-based approaches to improve surgical safety should be supplemented with additional focus on cognitive errors associated with surgical care.