Journal of Surgical Simulation 2017; 4: B: 4 - 4

Published: 11 May 2017


Oral presentation

Special Issue: Can cognitive psychology help us understand surgical safety issues?

Narinder Kapur
Corresponding author: Narinder Kapur, Research Department of Clinical Psychology, University College London, London, UK. Email:


While human factors approaches to surgical error are well established, there has been relatively less attention as to how the field of cognitive psychology can help us understand surgical safety issues. An overview of cognitive considerations is provided, ranging from memory and attention lapses to unconscious bias. Similarities and differences between aviation and healthcare are considered, and two prototypical examples from each are considered from a cognitive psychology perspective. Taking a set of clinical never events, a possible framework for understanding cognitive factors that may contribute to adverse surgical events is considered, and how an ‘affordance’ framework may help in highlighting remedial approaches is discussed. Preliminary data are provided on a retrospective analysis of adverse events reported to the Confidential Reporting Systems in Surgery committee (CORESS), using the conceptual framework drawn up by Lawton et al.1. Drawing on some initial findings, possible remedial interventions, such as perceptual training for perceptual identification errors are discussed.


1.   Lawton R, McEachan RRC, Giles SJ, Sirriyeh R, Watt IS, Wright J. Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review. BMJ Qual Saf 2012; 21: 369-380.


surgical error; human factors; cognitive; surgical safety; patient safety

Additional Information

This presentation was given at the one day symposium, Current Approaches to Understanding Surgical Error, University of Leeds, Leeds, UK, on 9 December 2016.

Conflicts of interest: none declared.