BMJ Qual Saf 20:599-603 doi:10.1136/bmjqs.2010.048983
  • Original research

A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes

  1. Paul Barach2,5
  1. 1TNO Human Factors, Soesterberg, The Netherlands
  2. 2Department of Perioperative Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
  3. 3TNO Quality of Life, Leiden/Hoofddorp, The Netherlands
  4. 4Department of Paediatric Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
  5. 5Patient Safety Center of the University Medical Center Utrecht, Utrecht, The Netherlands
  1. Correspondence to Jan Maarten Schraagen, TNO Human Factors, PO Box 23, 3769 ZG Soesterberg, The Netherlands; jan_maarten.schraagen{at}
  • Accepted 7 March 2011
  • Published Online First 13 April 2011


Objective Paediatric cardiac surgery has a low error tolerance and demands high levels of cognitive and technical performance. Growing evidence suggests that further improvements in patient outcomes depend on system factors, in particular, effective team skills. The hypotheses that small intraoperative non-routine events (NREs) can escalate to more serious situations and that effective teamwork can prevent the development of serious situations were examined to develop a method to assess these skills and to provide evidence for improvements in training and performance.

Methods This mixed-method design, using both quantitative and qualitative measures, relied on trained human factor observers who observed and coded NREs and teamwork elements from the time of patient arrival into the operating room to patient handover to the intensive care unit. Real-time teamwork observations were coupled with microsystem preparedness measures, operative duration, assessed difficulty of the operation and patient outcome measures. Behaviour was rated based on whether it hindered or enhanced teamwork.

Results 40 paediatric cardiac surgery cases were observed. Surgeons displayed better teamwork during complicated procedures, particularly during the surgical bypass/repair epoch. More procedural NREs were associated with a more complicated postoperative course (Muncomplicated=9.08; Mminor complications=11.11; Mmajor morbidity=14.60, F(2,26)=3.46, p<0.05). Procedural NREs decreased substantially over time (M1=13.5; M2=7.1, F(1,37)=33.07, p<0.001).

Conclusions Structured observation of effective teamwork in the operating room can identify substantive deficiencies in the system and conduct of procedures, even in otherwise successful operations. High performing teams are more resilient displaying effective teamwork when operations become more difficult.


  • Linked article 040105.

  • Funding TNO Quality of Life, Wassenaarseweg 56, Leiden, The Netherlands.

  • Competing interests TS and FH are employed by the University Medical Center Utrecht and were part of the team under study.

  • Ethics approval Full institutional ethics approval was obtained and consent was acquired from all PCS team members. Ethics approval was provided by IRB, University Medical Centre Utrecht.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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