An empirical investigation of surgical flow disruptions and their relationship to surgical errors

Douglas A. Wiegmann, Andrew W. Elbardissi, Joseph A. Dearani, Thoralf M. Sundt

Research output: Chapter in Book/Report/Conference proceedingConference contribution

5 Scopus citations

Abstract

Surgical flow disruptions can significantly increase the probability of surgical errors. However, little is known about the frequency and nature of surgical flow disruptions, making the development of evidencebased interventions extremely difficult. The goal of this project was to prospectively study surgical errors and their relationship to surgical flow disruptions within the context of cardiac surgery. A trained observer recorded surgical errors and flow disruptions during 31 cardiac operations over a three-week period. Flow disruptions were then reviewed and analyzed by an interdisciplinary team of surgical and human factors experts. Results revealed that flow disruptions consisted of teamwork/communication failures, equipment and technology problems, extraneous interruptions, training-related distractions, and resource accessibility issues. Errors increased significantly with increases in flow disruptions. Teamwork/communication failures were the strongest predictor of surgical errors. These findings provide preliminary data for developing evidenced-based error management and patient safety programs within cardiac surgery.

Original languageEnglish (US)
Title of host publicationProceedings of the Human Factors and Ergonomics Society 50th Annual Meeting, HFES 2006
Pages1049-1053
Number of pages5
StatePublished - Dec 1 2006
Event50th Annual Meeting of the Human Factors and Ergonomics Society, HFES 2006 - San Francisco, CA, United States
Duration: Oct 16 2006Oct 20 2006

Publication series

NameProceedings of the Human Factors and Ergonomics Society
ISSN (Print)1071-1813

Other

Other50th Annual Meeting of the Human Factors and Ergonomics Society, HFES 2006
CountryUnited States
CitySan Francisco, CA
Period10/16/0610/20/06

ASJC Scopus subject areas

  • Human Factors and Ergonomics

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  • Cite this

    Wiegmann, D. A., Elbardissi, A. W., Dearani, J. A., & Sundt, T. M. (2006). An empirical investigation of surgical flow disruptions and their relationship to surgical errors. In Proceedings of the Human Factors and Ergonomics Society 50th Annual Meeting, HFES 2006 (pp. 1049-1053). (Proceedings of the Human Factors and Ergonomics Society).