TableĀ 1

Glitch categories with definition and examples

Glitch categoryDefinitionExamples
AbsenceAbsence of theatre staff member, when requiredCirculating nurse not available to get equipment
CommunicationDifficulties in communication among team membersRepeat requests, incorrect terminology and misinterpretations
DistractionsAnything causing distraction from taskPhone calls/bleeps, loud music requiring to be turned down
EnvironmentAspects of the working environment causing difficultyLow lighting or variable temperature during operation causing difficulties
Equipment designIssues arising from equipment design, that would not otherwise be corrected with training or maintenanceCompatibility problems with different implant systems; equipment blockage
MaintenanceFaulty or poorly maintained equipmentBattery depleted during use, blunt equipment
Health and safetyAny observed physical risk to personnelMask violations, food/drink in theatre
Planning and preparationInstances that may otherwise been avoided with appropriate prior planning and preparationInsufficient equipment resources, staffing levels and training
Patient relatedIssues relating to the physiological status of the patientDifficulty in extracting previous implants, unexpected anatomically related surgical difficulty and anaphylaxis
Process deviationIncomplete or reordered completion of standard tasksUnnecessary equipment opened
SlipsPsychomotor errorsDropped instruments
TrainingRepetition or delay of operative steps due to trainingConsultant corrects assistants operating technique
WorkspaceEquipment or theatre layout issuesDesterilising of equipment/scrubbed staff on environment