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Appl Ergon. 1998 Dec;29(6):409-14.

Errors enacted during endoscopic surgery--a human reliability analysis.

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Department of Surgery, Ninewells Hospital and Medical School, University of Dundee, Scotland, UK.


The aim of the study was to document the nature and incidence of surgical errors enacted during laparoscopic surgery in order to direct future research and surgical training. A modified Human Reliability Analysis (HRA) approach, based on direct observation, was adopted to categorise and record errors encountered during the practice of laparoscopic cholecystectomy. This study confirmed the applicability and usefulness of an observational methodology in the assessment of human error in endoscopic surgical performance. The study identified aspects of the design and usage of instruments, surgical training and the differences between tasks which needed further directed research in order to identify underlying performance shaping factors (PSFs) and so reduce error rates.

[Indexed for MEDLINE]

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