Elsevier

Surgery

Volume 142, Issue 5, November 2007, Pages 658-665
Surgery

Surgical outcome research
Disruptions in surgical flow and their relationship to surgical errors: An exploratory investigation

Presented at the Paper Sessions of the 92nd Annual Meeting of the American College of Surgeons Clinical Congress.
https://doi.org/10.1016/j.surg.2007.07.034Get rights and content

Background

Disruptions in surgical flow have the potential to increase the occurrence of surgical errors; however, little is known about the frequency and nature of surgical flow disruptions and their effect on the etiology of errors, which makes the development of evidence-based interventions extremely difficult. The goal of this project was to study surgical errors and their relationship to surgical flow disruptions in cardiovascular surgery prospectively to understand better the effect of these disruptions on surgical errors and ultimately patient safety.

Methods

A trained observer recorded surgical errors and flow disruptions during 31 cardiac surgery operations over a 3-week period and categorized them by a classification system of human factors. Flow disruptions were then reviewed and analyzed by an interdisciplinary team of experts in operative and human factors.

Results

Flow disruptions consisted of teamwork/communication failures, equipment and technology problems, extraneous interruptions, training-related distractions, and issues in resource accessibility. Surgical errors increased significantly with increases in flow disruptions. Teamwork/communication failures were the strongest predictor of surgical errors.

Conclusion

These findings provide preliminary data to develop evidenced-based error management and patient safety programs within cardiac surgery with implications to other related surgical programs.

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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Supported in part by the NIH Roadmap Multidisciplinary Clinical Research Career Development Award Grant (K12/NICHD)-HD49078.

D.A. and A.E. contributed equally to this work.

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