Non-technical Errors, a Hidden Contributor to Patient Mortality in Emergency General Surgery

OBJECTIVE: To characterize the incidence, clinical phase, team responsibility, and behavioral drivers of non-technical errors (NTEs) associated with death in emergency general surgery to inform future NTS improvement strategies. BACKGROUND DATA: Deficiencies in surgical non-technical skills (NTS) contribute substantially to patient harm. Emergency general surgery is common, complex, and high-risk, yet characteristics of NTEs remain unknown. METHODS: Retrospective cohort study including all emergency general surgical mortalities with an adverse event or area of concern from a national, mandated, peer-reviewed mortality audit (2012-2019). Cases were independently assessed by two reviewers using a validated tool to identify and characterize NTEs. RESULTS: NTEs occurred in 790/1164 (67.9%) deaths, comprising 1053 unique errors. Situational awareness errors occurred most (518/1053, 49.3%), followed by decision-making errors (431/1053, 40.9%). Most errors arose from few recurring behaviors: for situational awareness, failure to recognize clinical signs (92/518, 17.8%), failure to appreciate illness severity (75/518, 14.5%), and missed diagnosis (73/518, 14.1%); for decision-making, failure to initiate appropriate intervention/investigation (99/431, 23%) or incorrect operation performed (71/431, 16.5%). Error distribution differed significantly (χ²=1325, P<0.01), with 947/1053 (89.9%) occurring outside the operating theatre. Surgical teams were responsible for 652/888 (73.4%) single-team errors and 109/116 (94%) multi-team errors; non-surgical teams were responsible for 235/888 (26.5%) single-team errors and 112/116 (96.6%) multi-team errors. CONCLUSIONS: NTEs associated with patient death predominantly occurred outside the operating theatre, arose from few recurrent behaviors, and involved surgical and non-surgical teams. Future NTS improvement strategies must extend beyond the theatre, be behaviorally informed, and target all teams involved.