Understanding how human factors can cause errors in the operating theatre

Abstract

Human error can be defined as the ‘failure of a planned action’ ( Reason, 2005: 57 ). The study of human and team error in the operating theatre is slowly gathering momentum as we acquire further evidence that many patient iatrogenic injuries and adverse events have human fallibility at their root ( Department of Health, 2009 ). Effective teamwork and communication in safety-critical environments such as operating theatres involve the cooperation of multiple practitioners with varying levels of expertise and seniority ( Sasou and Reason, 1999 ). Despite innovative ideas such as the World Health Organization's (WHO) Safe Surgery Checklist, evidence suggests that shortfalls in communication, shared cognition and the presence of authority gradients—described as the failure of efficient and effective communication as a result of a perceived hierarchy within the team ( Cosby and Croskerry, 2004 )—continue to affect patient safety in the operating theatre. This paper explores some of the potential barriers to free flow of communication, as well as investigating how operating department practitioners' (ODPs) mastery of safety sciences including human factors could potentially increase safety and reduce avoidable harm.