Abstract
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.
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More From: Proceedings of the Human Factors and Ergonomics Society Annual Meeting
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