Surgical outcome researchDisruptions in surgical flow and their relationship to surgical errors: An exploratory investigation
Section snippets
Sample of surgical cases
A convenience sample of 31 cardiac surgical operations was obtained across a 3-week study period. These cases were chosen randomly from the nonemergency operative schedule of cardiovascular surgeons who agreed to allow observations to take place in their operating room. All operations were performed at a single medical institution and multiple procedures were observed, which include coronary artery bypass grafting (CABG; n = 13), valve repair/replacement (n = 6), CABG and valve repair (n = 4),
Surgical errors
Most errors observed during this study were relatively minor. For example, “surgeon put purse string suture that overlapped the previous purse string suture; suture was removed and reinserted.” “An aortic valve suture was incorrectly placed, requiring correction by the surgeon after all the sutures had been placed.” “After the surgeon completed anastomosis to the coronary artery, it leaked, requiring an additional suture to be placed to seal anastomosis.” “Retrograde cardioplegia cannula
Discussion
The results of the current study indicate that operative errors that occur during cardiac surgery are associated with surgical flow disruptions. Generally, these disruptions consisted of a variety of systemic factors, which included teamwork problems, equipment factors, extraneous distractions, training-related issues, and resource accessibility. These surgical disruptions may affect negatively the surgical team’s ability to remain fully engaged mentally during a case. Surgeons often rate
Conclusion
Although some studies of surgical error have occurred in the actual OR environment,12, 22 most research efforts have used sentinel event analyses, staff surveys, and surgical simulations to study the occurrence and causes of errors. This study, therefore, contributes to the growing number of prospective observational studies to identify the incidence of surgical errors, surgical flow disruptions, and the relationship that exists among these human factors. The results of the current study
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Cited by (0)
Supported in part by the NIH Roadmap Multidisciplinary Clinical Research Career Development Award Grant (K12/NICHD)-HD49078.
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D.A. and A.E. contributed equally to this work.