title: Expert Intraoperative Judgment and Decision-Making: Defining the Cognitive Competencies for Safe Laparoscopic Cholecystectomy.
abstract: 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.
  
  
  METHODS
  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.
authors: Department of Surgery, McGill University, Montreal, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Canada. Electronic address: amin.madani@mail.mcgill.ca.
authors: Amin
authors: A
authors: Madani
authors: Department of Surgery, McGill University, Montreal, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Canada.
authors: Yusuke
authors: Y
authors: Watanabe
authors: Department of Surgery, McGill University, Montreal, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Canada.
authors: Liane S
authors: LS
authors: Feldman
authors: Department of Surgery, McGill University, Montreal, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Canada.
authors: Melina C
authors: MC
authors: Vassiliou
authors: Department of Surgery, McGill University, Montreal, Canada.
authors: Jeffrey S
authors: JS
authors: Barkun
authors: Department of Surgery, McGill University, Montreal, Canada; Arnold and Blema Steinberg Medical Simulation Centre, Faculty of Medicine, McGill University, Montreal, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Canada.
authors: Gerald M
authors: GM
authors: Fried
authors: Department of Surgery, McGill University, Montreal, Canada; Arnold and Blema Steinberg Medical Simulation Centre, Faculty of Medicine, McGill University, Montreal, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Canada.
authors: Rajesh
authors: R
authors: Aggarwal
mesh_terms: D000328:Adult; D001652:Bile Ducts / Q000293:injuries; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects / Q000523:psychology* / Q000592:standards; D002983:Clinical Competence; D000066491:Clinical Decision-Making; D003071:Cognition; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D007600:Judgment; D008297:Male; D019300:Medical Errors / Q000009:adverse effects / Q000517:prevention & control / Q000523:psychology*; D008875:Middle Aged; D061214:Patient Safety; D036301:Qualitative Research; D066231:Surgeons / Q000523:psychology*; D013647:Task Performance and Analysis