Surgical flow disruptions can significantly increase the probability of surgical errors. However, little is known about the frequency and nature of surgical flow disruptions, making the development of evidence-based interventions extremely difficult. The goal of this project was to prospectively study surgical errors and their relationship to surgical flow disruptions within the context of cardiac surgery. A trained observer recorded surgical errors and flow disruptions during 31 cardiac operations over a three-week period. Flow disruptions were then reviewed and analyzed by an interdisciplinary team of surgical and human factors experts. Results revealed that flow disruptions consisted of teamwork/communication failures, equipment and technology problems, extraneous interruptions, training-related distractions, and resource accessibility issues. Errors increased significantly with increases in flow disruptions. Teamwork/communication failures were the strongest predictor of surgical errors. These findings provide preliminary data for developing evidenced-based error management and patient safety programs within cardiac surgery.
[1]
Charles Vincent,et al.
Systems Approaches to Surgical Quality and Safety: From Concept to Measurement
,
2004,
Annals of surgery.
[2]
J. Reason,et al.
Human factors and cardiac surgery: a multicenter study.
,
2000,
The Journal of thoracic and cardiovascular surgery.
[3]
M. Alexander.
To Err is Human.
,
2006,
Journal of infusion nursing : the official publication of the Infusion Nurses Society.
[4]
A. Gawande,et al.
Accidental deaths, saved lives, and improved quality.
,
2005,
The New England journal of medicine.
[5]
R. Reznick,et al.
Communication failures in the operating room: an observational classification of recurrent types and effects
,
2004,
Quality and Safety in Health Care.
[6]
T. Orlick,et al.
Mental readiness in surgeons and its links to performance excellence in surgery.
,
1995,
Journal of pediatric orthopedics.