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Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study
  1. Ayse P Gurses1,2,3,4,
  2. George Kim1,2,3,
  3. Elizabeth A Martinez5,
  4. Jill Marsteller1,2,4,6,
  5. Laura Bauer2,
  6. Lisa H Lubomski1,2,
  7. Peter J Pronovost1,2,4,7,8,
  8. David Thompson1,2,7
  1. 1Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  2. 2Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  3. 3Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  4. 4Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
  5. 5Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
  6. 6Center for Health Services and Outcomes Research, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
  7. 7Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
  8. 8Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  1. Correspondence to Dr Ayse P Gurses, 1909 Thames Street, 2nd floor, Baltimore, MD 21231, USA; agurses1{at}


Background Cardiac surgery is a complex, high-risk procedure with potential vulnerabilities for patient safety. The evidence base describing safety hazards in the cardiovascular operating room is underdeveloped but is essential to guide future safety improvement efforts.

Objective To identify and categorise hazards (anything that has the potential to cause a preventable adverse patient safety event) in the cardiovascular operating room.

Methods An interdisciplinary team of researchers used prospective methods, including direct observations, contextual inquiry and photographs to collect hazard data pertaining to the cardiac surgery perioperative period, which started immediately before the patient was transferred to the operating room and ended immediately after patient handoff to the post-anaesthesia/intensive care unit. Data were collected between February and September 2008 in five hospitals. An interdisciplinary approach that included a human factors and systems engineering framework was used to guide the study.

Results Twenty cardiac surgeries including the corresponding handoff processes from operating room to post-anaesthesia/intensive care unit were observed. A total of 58 categories of hazards related to care providers (eg, practice variations), tasks (eg, high workload), tools and technologies (eg, poor usability), physical environment (eg, cluttered workspace), organisation (eg, hierarchical culture) and processes (eg, non-compliance with guidelines) were identified.

Discussion Hazards in cardiac surgery services are ubiquitous, indicating numerous opportunities to improve safety. Future efforts should focus on creating a stronger culture of safety in the cardiovascular operating room, increasing compliance with evidence-based infection control practices, improving communication and teamwork, and developing a partnership among all stakeholders to improve the design of tools and technologies.

  • Classification of hazards
  • safety
  • cardiac surgical procedures
  • operating rooms
  • human engineering
  • hand-off
  • human error
  • human factors
  • health services research
  • patient safety
  • checklists
  • communication
  • continuous quality improvement
  • adverse events
  • epidemiology and detection
  • anaesthesia
  • checklists
  • critical care
  • evidence-based medicine
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  • Funding The research was funded in part by the Society of Cardiovascular Anaesthesiologists Foundation (SCAF) as part of their FOCUS Initiative. The FOCUS Initiative is a collaborative project of the Society of Cardiovascular Anaesthesiologists, the SCA Foundation, and the Johns Hopkins University Quality and Safety Research Group. FOCUS is funded exclusively by the SCA Foundation; the following received support for this research: Drs Marsteller, Pronovost, Gurses, Lubomski and Thompson, and Ms Bauer. Ayse P Gurses was supported in part by the Agency for Healthcare Research and Quality K01 grant no. HS018762. Elizabeth A Martinez was supported by the Agency for Healthcare Research and Quality K08 grant no. HS013904- 02.

  • Competing interests Dr Gurses reports receiving grant or contract support from the National Patient Safety Foundation, consulting fees from a grant funded by the National Council of State Boards of Nursing, and an honorarium from a healthcare system for speaking at a patient safety workshop. Dr Lubomski reports receiving funding from the Michigan Health & Hospital Association Keystone Center for Quality and Patient Safety, and consultancy fees from the Society for Paediatric Anaesthesia. Dr Thompson was supported by the SCA Foundation, but has no other conflicts to report. Dr Pronovost reports receiving grant or contract support from the Agency for Healthcare Research and Quality, the National Institutes of Health, the Robert Wood Johnson Foundation, and The Commonwealth Fund for research related to measuring and improving patient safety; honoraria from various hospitals and healthcare systems and the Leigh Bureau to speak on quality and safety; consultancy with the Association for Professionals in Infection Control and Epidemiology, Inc; and book royalties for authoring Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out.

  • Ethics approval Ethics approval was provided by Johns Hopkins University Institutional Review Board (IRB) and the IRBs of participating institutions.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The survey, observation, interview and contextual inquiry data are housed within the Armstrong Institute for Patient Safety and Quality at the Johns Hopkins University, and are available to the original research team members who have active IRB approval. The data have also been made available to the Society of Cardiovascular Anaesthesiologists through a contract with Johns Hopkins Medicine.

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