BMJ Qual Saf 21:807-809 doi:10.1136/bmjqs-2012-001135
  • Editorial

Understanding safety and performance in the cardiac operating room: from ‘sharp end’ to ‘blunt end’

Editor's Choice
  1. Douglas Wiegmann2
  1. 1Department of Surgery, Cedars-Sinai Medical Centre, Los Angeles, California, USA
  2. 2Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Wisconsin Madison, WI, USA
  1. Correspondence to Dr Ken Catchpole, Department of Surgery, Cedars-Sinai Medical Center, Suite 302, 8797 Beverly Blvd, Los Angeles, CA 90048, USA; ken.catchpole{at}

Successful surgery requires a patient with an accurate diagnosis, a treatment plan with an acceptable chance of success, a skilled surgeon and supporting team, a range of equipment, drugs and disposable items to support complex surgical tasks, a follow-up care team to ensure appropriate postoperative recovery and discharge, and an organisation that supports the people and helps to coordinate the delivery of all aspects of care. The tragic consequences that can ensue from failures across this broad range of system components came to light in the case of paediatric cardiac surgery some 15 years ago. Incidents in Winnipeg, Canada,1 and Bristol, UK,2 led to inquiries into surgical deaths that were among the first to highlight the complex range of systemic influences on surgical performance. These thorough analyses revealed a huge range of ‘blunt end’ system problems: surgical volumes, leadership and organisational issues, dysfunctional communication between teams and departments, and the basic predisposition to error imposed by the complex amalgam of team, task, process and technical ability within the surgery itself.

Emerging partly from those events was perhaps the seminal observational multidisciplinary study in surgical care conducted by Carthey and de Leval et al.3 They demonstrated that even successful operations were often fraught with large numbers of potential problems that arose as a result of systems issues. More importantly for outcomes-based research, they found that enough of these minor problems in one operation could contribute to increased morbidity and mortality.4 Furthermore, the actions of the team in recovering from these problems could make the difference between a good and a poor outcome.5 This study was therefore critical in making direct inferential links between surgical outcomes, human factors and systems issues.

Subsequent research developed these observational techniques and a suggested model for understanding error causation in surgery. …