Original communicationImproving patient safety by identifying latent failures in successful operations
Section snippets
Materials and methods
This was a prospective, observational study of intraoperative events in 2 different types of intraoperative care. Pediatric cardiac operation features multiple specialties, close coupling of concurrent tasks, uncertainty, changing plans, and a high workload,13 and was chosen as a model of complex operation.3 Elective orthopedic operation was investigated in another hospital in which the orthopedic operations were high volume, low risk,14 highly proceduralized, and a relatively invariant type of
Results
Forty-two operations were studied: 24 in pediatrics, and 18 in orthopedics. All operations were regarded as having a successful outcome with no 28-day mortality. None of the operations studied were considered to be unusual in terms of the individuals involved, the procedures themselves, or the condition of the patients. Often, the same members of the operating room team were involved, but neither members nor roles were always identical. In orthopedic operation, the first surgeon was always a
Discussion
Our study supports the hypotheses that complications during operations can arise from an escalation of smaller problems and that effective teamwork can mitigate these problems. In this small sample of competent practitioners, it was not a lack of technical knowledge and skills that were the cause of these problems, but the context in which the operation took place. The problems identified in these operations reflected individual errors by members of the team, failures in group processes,
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Cited by (0)
Supported in part by the Patient Safety Research Programme, Department of Health, UK.
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T.D. and G.H. are Directors of Atrainability Ltd, which provides non-technical skills training for aviation and healthcare.