Background
Disruptions in surgical flow have the potential to increase the occurrence of surgical
errors; however, little is known about the frequency and nature of surgical flow disruptions
and their effect on the etiology of errors, which makes the development of evidence-based
interventions extremely difficult. The goal of this project was to study surgical
errors and their relationship to surgical flow disruptions in cardiovascular surgery
prospectively to understand better the effect of these disruptions on surgical errors
and ultimately patient safety.
Methods
A trained observer recorded surgical errors and flow disruptions during 31 cardiac
surgery operations over a 3-week period and categorized them by a classification system
of human factors. Flow disruptions were then reviewed and analyzed by an interdisciplinary
team of experts in operative and human factors.
Results
Flow disruptions consisted of teamwork/communication failures, equipment and technology
problems, extraneous interruptions, training-related distractions, and issues in resource
accessibility. Surgical errors increased significantly with increases in flow disruptions.
Teamwork/communication failures were the strongest predictor of surgical errors.
Conclusion
These findings provide preliminary data to develop evidenced-based error management
and patient safety programs within cardiac surgery with implications to other related
surgical programs.
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Article info
Publication history
Accepted:
July 13,
2007
Footnotes
Supported in part by the NIH Roadmap Multidisciplinary Clinical Research Career Development Award Grant (K12/NICHD)-HD49078.
Identification
Copyright
© 2007 Mosby, Inc. Published by Elsevier Inc. All rights reserved.
