Table 2 Taxonomy of non-operating procedural errors
Classification of problemExample
AbsenceCirculating nurse out of theatre when she is needed to get clipper for cystic duct/artery
Coordination/communication problemSurgeon asks nurse ×3 for vascular sling before receiving it
DistractionMobile phone rings loudly during case
Equipment/workspace management problemDiathermy unplugged when required
Equipment operation problemTransducer not zeroed giving false readings
Equipment problemSutures break
Expertise/skill problemConsultant surgeon captures error made by trainee surgeon
External resource problemPiece of equipment is missing from standard set
Patient-sourced procedural difficultiesDifficult anatomy causing operative difficulties
Planning problemDifficult intubation anticipated but not planned for
Procedure-related errorArterial clamp time not recorded
Non-operative psychomotor errorRetractor is dropped
Resource management problemSurgeon leaves assistant to close without confirming ability to do so
Safety consciousness problemAnaesthetist not wearing face mask in carotid endarterectomy, despite being protocol during vascular cases
Vigilance/awareness problemAnaesthetist fails to note significant drop in arterial pressure