Abstract

This chapter describes the growing knowledge of factors that affect human performance and how these factors contribute to adverse surgical outcomes. Highlights include factors that affect performance, including teamwork, communication, and environmental and organizational factors. Tables and figures include a schematic depiction of the process by which system failures may lead to injury, accepted definitions of patient safety related terms, hand off coordination and communication objectives, and the Systems Engineering Initiative for Patient Safety model of work system and patient safety. This review contains 3 figures, 3 tables, and 78 references Key Words: Patient safety, systems science, medical error, adverse events, systems engineering, teamwork, communication, organizational resilience, high reliability organizations

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