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

• Published in: Journal of the American College of Surgeons Vol. 221; no. 5; pp. 931 - 940.e8
• Main Authors: Madani, Amin, MD, Watanabe, Yusuke, MD, Feldman, Liane S., MD, FRCSC, FACS, Vassiliou, Melina C., MD, Med, FRCSC, FACS, Barkun, Jeffrey S., MD, MSc, FRCSC, FACS, Fried, Gerald M., MD, FRCSC, FACS, Aggarwal, Rajesh, MBBS, MA, PhD, FRCS
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.11.2015
• Subjects: Adult; Bile Ducts - injuries; Cholecystectomy, Laparoscopic - adverse effects; Cholecystectomy, Laparoscopic - psychology; Cholecystectomy, Laparoscopic - standards; Clinical Competence; Clinical Decision-Making; Cognition; Female; Humans; Interviews as Topic; Judgment; Male; Medical Errors - adverse effects; Medical Errors - prevention & control; Medical Errors - psychology; Middle Aged; Patient Safety; Qualitative Research; Surgeons - psychology; Surgery; Task Performance and Analysis; CTA; CVS; HTA; hierarchical task analysis; subject-matter expert; cognitive task analysis; critical view of safety; SME; IQR; interquartile range
• ISSN: 1072-7515; 1879-1190
• DOI: 10.1016/j.jamcollsurg.2015.07.450

Background 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.