Expert Intraoperative Judgment and Decision-Making: Defining the Cognitive Competencies for Safe Laparoscopic Cholecystectomy

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• 作者：Amin Madani ; MD^a ; ^c ; ^{amin.madani@mail.mcgill.ca" class="auth_mail" title="E-mail the corresponding author} ; Yusuke Watanabe ; MD^a ; ^c ; Liane S. Feldman ; MD ; FRCSC ; FACS^a ; ^c ; Melina C. Vassiliou ; MD ; Med ; FRCSC ; FACS^a ; ^c ; Jeffrey S. Barkun ; MD ; MSc ; FRCSC ; FACS^a ; Gerald M. Fried ; MD ; FRCSC ; FACS^a ; ^b ; ^c ; Rajesh Aggarwal ; MBBS ; MA ; PhD ; FRCS^a ; ^b ; ^c
• 关键词：CTA ; cognitive task analysis ; CVS ; critical view of safety ; HTA ; hierarchical task analysis ; IQR ; interquartile range ; SME ; subject-matter expert
• 刊名：Journal of the American College of Surgeons
• 出版年：2015
• 出版时间：November 2015
• 年：2015
• 卷：221
• 期：5
• 页码：931-940.e8
• 全文大小：955 K

文摘

Bile duct injuries from laparoscopic cholecystectomy remain a significant source of morbidity and are often the result of intraoperative errors in perception, judgment, and decision-making. This qualitative study aimed to define and characterize higher-order cognitive competencies required to safely perform a laparoscopic cholecystectomy.

Study Design

Hierarchical and cognitive task analyses for establishing a critical view of safety during laparoscopic cholecystectomy were performed using qualitative methods to map the thoughts and practices that characterize expert performance. Experts with more than 5 years of experience, and who have performed at least 100 laparoscopic cholecystectomies, participated in semi-structured interviews and field observations. Verbal data were transcribed verbatim, supplemented with content from published literature, coded, thematically analyzed using grounded-theory by 2 independent reviewers, and synthesized into a list of items.

Results

A conceptual framework was created based on 10 interviews with experts, 9 procedures, and 18 literary sources. Experts included 6 minimally invasive surgeons, 2 hepato-pancreatico-biliary surgeons, and 2 acute care general surgeons (median years in practice, 11 [range 8 to 14]). One hundred eight cognitive elements (35 [32%] related to situation awareness, 47 [44%] involving decision-making, and 26 [24%] action-oriented subtasks) and 75 potential errors were identified and categorized into 6 general themes and 14 procedural tasks. Of the 75 potential errors, root causes were mapped to errors in situation awareness (24 [32%]), decision-making (49 [65%]), or either one (61 [81%]).

Conclusions

This study defines the competencies that are essential to establishing a critical view of safety and avoiding bile duct injuries during laparoscopic cholecystectomy. This framework may serve as the basis for instructional design, assessment tools, and quality-control metrics to prevent injuries and promote a culture of patient safety.