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Morgan and colleagues elegantly propose the glitch methodology as an
effective means to identify process deviations that could impact on the
quality or speed of surgical procedures (1). We support the authors'
suggestion that the analysis of glitch patterns may facilitate the
development of interventions to improve patient safety in the operating
theatre across a range of domains.
The development of a common...
The development of a common method indeed seems possible. Using a
similar methodology, exclusively in vascular surgery, we have shown
remarkably similar results (2,3). The temporal pattern of glitches
reported in vascular procedures (40% within first quarter, 75% within
first half), reflects our previous data, in which many early intra
operative errors can be attributed to poor preoperative planning- an area
that we are currently assessing through the use of a novel software
application (PREPARE (4)).
Morgan et al.'s laudable efforts in this arena requires two
independent observers to record intraoperative glitches, one with a
background in human factors (HF) and one with surgical experience, with
good agreement between them. Interestingly, the authors identify that the
clinical observer consistently reports more glitches than the HF observer.
We feel that experienced health professionals working 'at the sharp end'
are ideally placed to identify problems with patient safety. For that
reason, we developed a method of identifying intraoperative error that can
be used by operating teams, as well as observers. The Imperial College
Error CAPture record (ICECAP) prompts structured reflection of
intraoperative error during post-operative debriefing sessions with team
members (5), and is being used in our UK multi-centre patient safety study
in vascular surgery (4,6). Similar to the glitch classifications used by
Morgan et al., ICECAP consists of six primary categories of error:
equipment; communication; procedure-independent pressures; technical;
safety awareness; patient-related, with twenty sub-categories used as
prompts. Operating teams have been able to recall 69.9% of all errors
recorded prospectively by a trained observer and nearly 79% of major
Team self-report of error has several benefits over prospective
observation, not least the fact that teams can feedback in real time, but
are also uniquely placed to understand the context of errors that occur
which is important in determining their significance. We believe that our
self-report methodology also helps to foster a culture of openness and
transparency to support patient safety- a key recommendation of the recent
Francis Report on Mid Staffs (7). Indeed the effect of culture may, in
agreement with Morgan et al., explain differences in glitch rates between
hospitals identified in their study.
In the light of our recent systematic review on surgery and
technology operating failures (8), we agree with Morgan et al. that
differences in glitch rates between sites and specialties are likely to be
dependent on differences in personnel, procedures and equipment.
Interestingly, Morgan et al. found that glitch rates varied significantly
in vascular. We have identified significant differences in error rates
between procedural sub-types in vascular (open versus endovascular) (3);
the types of treatment the authors observed may have influenced their
As Morgan and colleagues state, it is unlikely that we can improve
patient safety by addressing only one category of glitch, but
characterising error patterns and their significance are crucial first
steps in developing the wider surgical safety agenda.
1 Morgan L, et al. Capturing intraoperative process deviations using
a direct observational approach: the glitch method, BMJ Open 2013; 3:
2 Morbi AHM, et al. Reducing Error and Improving Efficiency during
Vascular Interventional Radiology: Implementation of a Preprocedural Team
Rehearsal. Radiology. 2012:264(2):473-483.
3 Albayati MA, et al. Identification of patient safety improvement
targets in successful vascular and endovascular procedures: analysis of
251 hours of complex arterial surgery. Eur J Vasc Endovasc Surg.
4 Cardiovascular Safety Group Research Programme. Accessed Jan 16,
5 Mason SL, et al. Design and validation of an error capture tool for
quality evaluation in the vascular and endovascular surgical theatre. Eur
J Vasc Endovasc Surg. 2012; 45(3):248-254.
6 UK Clinical Research Network. UK LEAP. Accessed Jan 16, 2014.
7 Francis R, The Mid Staffordshire NHS Foundation Trust Inquiry,
2013. Accessed Jan 16, 2014. http://www.midstaffspublicinquiry.com/report
8 Weerakkody RA, et al. Surgical technology and operating-room safety
failures: a systematic review of quantitative studies. BMJ Quality and
Safety 2013; 22(9): 710-718.