Absence | Circulating nurse out of theatre when she is needed to get clipper for cystic duct/artery |
Coordination/communication problem | Surgeon asks nurse ×3 for vascular sling before receiving it |
Distraction | Mobile phone rings loudly during case |
Equipment/workspace management problem | Diathermy unplugged when required |
Equipment operation problem | Transducer not zeroed giving false readings |
Equipment problem | Sutures break |
Expertise/skill problem | Consultant surgeon captures error made by trainee surgeon |
External resource problem | Piece of equipment is missing from standard set |
Patient-sourced procedural difficulties | Difficult anatomy causing operative difficulties |
Planning problem | Difficult intubation anticipated but not planned for |
Procedure-related error | Arterial clamp time not recorded |
Non-operative psychomotor error | Retractor is dropped |
Resource management problem | Surgeon leaves assistant to close without confirming ability to do so |
Safety consciousness problem | Anaesthetist not wearing face mask in carotid endarterectomy, despite being protocol during vascular cases |
Vigilance/awareness problem | Anaesthetist fails to note significant drop in arterial pressure |