Glitch categories with definition and examples
| Glitch category | Definition | Examples |
|---|---|---|
| Absence | Absence of theatre staff member, when required | Circulating nurse not available to get equipment |
| Communication | Difficulties in communication among team members | Repeat requests, incorrect terminology and misinterpretations |
| Distractions | Anything causing distraction from task | Phone calls/bleeps, loud music requiring to be turned down |
| Environment | Aspects of the working environment causing difficulty | Low lighting or variable temperature during operation causing difficulties |
| Equipment design | Issues arising from equipment design, that would not otherwise be corrected with training or maintenance | Compatibility problems with different implant systems; equipment blockage |
| Maintenance | Faulty or poorly maintained equipment | Battery depleted during use, blunt equipment |
| Health and safety | Any observed physical risk to personnel | Mask violations, food/drink in theatre |
| Planning and preparation | Instances that may otherwise been avoided with appropriate prior planning and preparation | Insufficient equipment resources, staffing levels and training |
| Patient related | Issues relating to the physiological status of the patient | Difficulty in extracting previous implants, unexpected anatomically related surgical difficulty and anaphylaxis |
| Process deviation | Incomplete or reordered completion of standard tasks | Unnecessary equipment opened |
| Slips | Psychomotor errors | Dropped instruments |
| Training | Repetition or delay of operative steps due to training | Consultant corrects assistants operating technique |
| Workspace | Equipment or theatre layout issues | Desterilising of equipment/scrubbed staff on environment |