ABSTRACT
We report a case of a patient undergoing gastric bypass in which an improperly introduced bougie dilator resulted in esophageal perforation and we examine the matter using a human-factors approach. The Institute of Medicine's widely distributed 1999 report estimated that up to 98,000 Americans die each year as a result of preventable errors with the operating room being a particularly error-prone environment. The report suggests that the majority of errors are not the result of poor provider performance but instead are the result of inherent systems-based problems. Perforation can be associated with significant negative outcome; modifying factors include experience, appreciating anatomical details, and cognizance of mechanisms of perforation. Human-factors research reveals that 1) humans are prone to err and 2) the majority of errors are not the result of personal inadequacy but instead are the product of defects in the design of health care environmental systems in which that work occurs. Here during a highly complex surgical procedure a simple preventable human error occurred, one often associated with significant negative outcome. We suggest a simple solution in line with a human-factors approach that might prevent future occurrences.
