ReviewThe human factor in cardiac surgery: errors and near misses in a high technology medical domain
Section snippets
Capturing human factors in cardiac operations
In our study, data were collected from a questionnaire (Surgical Team Assessment Record) and from on-site observations made by a human factors researcher who attended the ASOs in 16 centers during an 18-month data collection period. Throughout the case the researcher took notes on the types of minor and major events (errors and problems) as they occurred. Minor events were errors that alone were not expected to have serious consequences for the patient; these included instrument handing errors
Critical incident and near-miss reporting in medicine
“A near miss is any situation which has clearly significant and potentially serious (safety related) consequences.” (Van der Schaaf and coworkers, 1991) [22].
Near-miss reporting systems are used widely in the nuclear [23], aviation 24, 25, chemical 22, 26, and railway industries [27]. Central to the concept of near misses is that some form of recovery took place; ie, an accident sequence was initiated and then either by chance or by the actions of an individual, team, or organization it was
Analysis of near misses in cardiac surgery
Critical incident and near-miss reporting that is based on human error taxonomies is in its infancy in the field of cardiac surgery. However, a few studies have described and analyzed near misses and recovery in cardiac operations, including the analysis of near misses in a series of ASOs by one cardiac surgeon [31]; the management of complications and failure to rescue patients who had coronary arterial bypass grafting (CABG) [15]; and case studies of near misses in patients who had cardiac
Lessons from other high-technology industries
In other high-technology industries, several practical lessons about near-miss and incident reporting have been learned which have implications for this field. The first problem is that of definition. Defining near misses in cardiac surgery is complicated by the need to distinguish between near misses and serious perioperative and postoperative complications. The definition of a near miss by de Leval and coworkers [31] may be used as an example. The need to go back onto bypass after the first
Recovering from a major error: prevention of a near miss
While surgeon A was doing a CABG procedure, after removing the cross-clamp the heart dilated and there was poor ventricular function. On visual inspection the heart was laboring and poorly perfused. The surgeon expressed doubts about the quality of his anastomosis and was concerned that the patient’s ischemic mitral regurgitation was worse than that noted in preoperative investigations. A transesophogeal echocardiogram was done, which confirmed that there was severe mitral regurgitation in the
Comment
There is an important role for human factors research in cardiac surgery. More research is needed to refine methods for the prospective analysis of surgical performance in the operating room and the retrospective analysis of near misses and critical incidents. By gaining a better understanding of the types of minor and major events, near misses, or critical incidents that occur during surgical procedures, we can teach a new generation of surgeons the necessary recovery strategies. Future
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