The Human Factor in Minimal Access Surgical Training: How Conscientious, Well-Trained Surgeons Make Mistakes

  • Rob BethuneEmail author
  • Nader Francis


This chapter describes the impact of human factors (non-technical skills) on minimally access surgery (MAS). Errors related to human factors affect up to 20 % of surgical patients, with a small proportion of these errors resulting in death. MAS is particularity challenging and the increased physical and cognitive strain can increase the number of errors impacting on patients. The various domains of human factors will be described using real life examples. These are: communication, teamwork, decision-making, situational awareness and coping with stress and fatigue. The aviation industry has developed effective methods to reduce human error and these will be discussed before detailing the attempts to replicate this training in surgery.


Human Factors Non-technical skills Error Communication Teamwork Briefings 


  1. 1.
    Mortality Statistics, Office of National Statistics. 2008.Google Scholar
  2. 2.
    Tang B, Hanna GB, Joice P, Cuschieri A. Identification and categorization of technical errors by Observational Clinical Human Reliability Assessment (OCHRA) during laparoscopic cholecystectomy. Arch Surg. 2004;139(11):1215–20.CrossRefPubMedGoogle Scholar
  3. 3.
    Kable AK, Gibberd RW, Spigelman AD. Adverse events in surgical patients in Australia. Int J Qual Health Care. 2002;14(4):269–76.CrossRefPubMedGoogle Scholar
  4. 4.
    van Wagtendonk I, Smits M, Merten H, Heetveld MJ, Wagner C. Nature, causes and consequences of unintended events in surgical units. Br J Surg. 2010;97(11):1730–40.CrossRefPubMedGoogle Scholar
  5. 5.
    Siu J, Maran N, Paterson-Brown S. Observation of behavioural markers of non-technical skills in the operating room and their relationship to intra-operative incidents. Surgeon. 2014. [Epub ahead of print].Google Scholar
  6. 6.
    McCrory B, LaGrange CA, Hallbeck M. Quality and safety of minimally invasive surgery: past, present, and future. Biomed Eng Comput Biol. 2014;6:1–11.PubMedCentralCrossRefPubMedGoogle Scholar
  7. 7.
    Flin R, O’Connor P, Crichton M. Safety at the Sharp End: a guide to non-technical skills. Burlington: Ashgate Publishing Limited, Surrey GU97PT, England; 2008.Google Scholar
  8. 8.
    Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. 2003;133(6):614–21.CrossRefPubMedGoogle Scholar
  9. 9.
    Baldwin PJ, Paisley AM, Brown SP. Consultant surgeons' opinion of the skills required of basic surgical trainees. Br J Surg. 1999;86(8):1078–82.CrossRefPubMedGoogle Scholar
  10. 10.
    Christian CK, Gustafson ML, Roth EM, Sheridan TB, Gandhi TK, Dwyer K, et al. A prospective study of patient safety in the operating room. Surgery. 2006;139(2):159–73.CrossRefPubMedGoogle Scholar
  11. 11.
    Lingard L, Espin S, Whyte S, Regehr G, Baker GR, Reznick R, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 2004;13(5):330–4.PubMedCentralCrossRefPubMedGoogle Scholar
  12. 12.
    Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–9.CrossRefPubMedGoogle Scholar
  13. 13.
    Braaf S, Manias E, Riley R. The 'time-out' procedure: an institutional ethnography of how it is conducted in actual clinical practice. BMJ Qual Saf. 2013;22(8):647–55.CrossRefPubMedGoogle Scholar
  14. 14.
    Ali M, Osborne A, Bethune R, Pullyblank A. Preoperative surgical briefings do not delay operating room start times and are popular with surgical team members. J Patient Saf. 2011;7(3):139–43.CrossRefPubMedGoogle Scholar
  15. 15.
    Bethune R, Sasirekha G, Sahu A, Cawthorn S, Pullyblank A. Use of briefings and debriefings as a tool in improving team work, efficiency, and communication in the operating theatre. Postgrad Med J. 2011;87(1027):331–4.CrossRefPubMedGoogle Scholar
  16. 16.
    Cuschieri A. Nature of human error: implications for surgical practice. Ann Surg. 2006;244(5):642–8.PubMedCentralCrossRefPubMedGoogle Scholar
  17. 17.
    Galinsky AD, Magee JC, Inesi ME, Gruenfeld DH. Power and perspectives not taken. Psychol Sci. 2006;17(12):1068–74.CrossRefPubMedGoogle Scholar
  18. 18.
    Kraus M, Piff P, Keltner D. Social class as culture: the convergence of resources and rank in the social realm. Curr Direct Psychol Sci. 2011;20:246–50.CrossRefGoogle Scholar
  19. 19.
    McCulloch P, Mishra A, Handa A, Dale T, Hirst G, Catchpole K. The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre. Qual Saf Health Care. 2009;18(2):109–15.CrossRefPubMedGoogle Scholar
  20. 20.
    Crossley J, Marriott J, Purdie H, Beard JD. Prospective observational study to evaluate NOTSS (Non-Technical Skills for Surgeons) for assessing trainees' non-technical performance in the operating theatre. Br J Surg. 2011;98(7):1010–20.CrossRefPubMedGoogle Scholar
  21. 21.
    Meier AH, Boehler ML, McDowell CM, Schwind C, Markwell S, Roberts NK, et al. A surgical simulation curriculum for senior medical students based on TeamSTEPPS. Arch Surg. 2012;147(8):761–6.CrossRefPubMedGoogle Scholar
  22. 22.
    Lisbon D, Allin D, Cleek C, Roop L, Brimacombe M, Downes C, et al. Improved knowledge, attitudes, and behaviors after implementation of TeamSTEPPS Training in an Academic Emergency Department: a pilot report. Am J Med Qual. 2014. [Epub ahead of print].Google Scholar
  23. 23.
    Bethune R, Blencowe NS. The trainee's voice: recognising the importance of preoperative briefings for surgical trainees. J Perioper Pract. 2014;24(3):56–8.PubMedGoogle Scholar

Copyright information

© Springer-Verlag London 2015

Authors and Affiliations

  1. 1.Colorectal SurgeryRoyal Devon and Exeter NHS Foundation TrustExeterUK
  2. 2.Colorectal SurgeryYeovil District Hospital NHS Foundation TrustSomersetUK

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