Wiegmann, Douglas A.

Background: Communication breakdowns are a common cause of adverse events in high consequence industries. It has become increasingly evident that within healthcare systems that poor communication is the causal factor of a large percentage of sentinel events. Methods: All communication exchanges between surgeon and perfusionist were monitored via observation for 18 cardiovascular surgery cases. Breakdowns were analyzed by stage and type of breakdown and a communication protocol designed based on the breakdowns. The protocol was then implemented, and use of the protocol was then monitored for 16 cardiovascular surgery cases. Results: Breakdowns decreased at each stage of cardiovascular surgery. Specific types of breakdowns decreased dramatically, most by more than half. Conclusions: This study shows that protocolizing communication can have a profound impact on communication breakdowns in the cardiovascular surgery operating theatre.

Background: Many researchers have previously explored the correlation between surgical flow disruptions (distractions and interruptions) and error in cardiac surgery, however there is no reliable tool to prospectively categorize surgical flow disruptions and the conditions that predispose a surgical team to error. Methods and Results: Two independent raters of different medical and human factors expertise observed 12 cardiovascular operations and iteratively designed a tool to characterize surgical flow disruptions and the latent factors that contribute to error. Categories to characterize surgical flow disruptions were based on human factors models of human error. Following the design period, both raters observed 10 surgical cases using the tool, to assess validity and inter-rater reliability. Rating agreement (weighted kappa) for each category across the 10 surgeries was moderate to very high, resulting in strong inter-rater reliability for each category on the surgical flow disruption tool (SFDT). Conclusions: This research depicts the development and utility of a tool to analyze surgical flow disruptions in the cardiovascular operating room with satisfactory inter-rater reliability. This tool is an important first step in systematically categorizing and measuring surgical flow disruptions and their impact on patient safety in the operating room.

Objective: Design a protocol for conducting preoperative briefings within the context of cardiovascular surgery. Method: A combined questionnaire and semi-structured focus group approach involving four subspecialties of surgical staff (n = 47) was conducted to gather information concerning (1) attitudes towards preoperative briefings, (2) logistical issues related to the conduct and content of briefings and (3) potential barriers that might impede implementation. Results: Analyses revealed consensus among surgical staff concerning briefing benefits (majority were very positive), duration (< 10 min), location (in the OR), content (procedure, patient, and equipment issues) and potential barriers (staff availability, attitudes, case scheduling, and lack of resources). Differences in opinions arose concerning timing of the brief (e.g., before vs. after patient enters OR) and the role of key participants. Discussion: A prototype checklist for conducting preoperative briefings was developed based on these results. Additional research is needed to implement and validate its effectiveness.

Objectives: To determine if the METI laparoscopic surgical simulator can discriminate between novices and experts and to assess learning curves among novices. Methods: Twenty novices and 5 experts performed five repetitions on the following modules: place arrow, retract, dissect, and traverse tube. For each module, median baseline performance was calculated. Novices performed 35 additional repetitions to assess learning with practice. Results: Experts out-performed novices at baseline for completion time of the dissect, place arrow, and traverse tube modules, as well as for error frequency on the traverse tube and retract modules. Novices' performance times improved significantly with practice, approaching the experts' baseline in all modules. Conclusion: The METI simulator exhibits construct validity on three of four basic-skills modules when considering completion time and on two modules when considering error frequency. Among novices, learning occurred with additional repetitions. Whether acquired skills transfer to the actual surgical environment has yet to be determined.

Cardiopulmonary bypass machines (CBM's), first developed in 1953, are commonly used during heart surgery to oxygenate blood and circulate it throughout the body while the heart is stopped. Although several advances have occurred in the engineering of perfusion pumps, the interface design of CBM's has not changed appreciably for several decades. The growing awareness of human error in medicine has highlighted the role that poorly designed medical devices can play in producing errors that cause patient harm. The purpose of this study, therefore, was to identify issues related to CBM design that may predispose surgical teams to make errors. The study utilized multiple research methods including observations, heuristic evaluations, structured interviews and usability assessments. Results revealed several fundamental design problems associated CBM displays, controls, alarms, and component integration, as well as communication and procedural issues. These data provide valuable information for redesigning CBM's to reduce errors and improve patient safety.

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 evidence-based 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.

Errors with serious consequences continue to occur at a high rate in many surgical specialties. In this study, the Human Factors Analysis and Classification System (Wiegmann & Shappell, 2003) was used to develop a structured interviewing tool for prospectively assessing the systemic factors that may predispose operating room (OR) personnel to making errors. Approximately 50% (n = 68) of all staff involved in patient care within the cardiac surgery OR at our institution participated, with an equal proportion represented across staff specialties (Surgeons, Anesthesiologists, Nurses, Perfusionists and Technicians). Results identified a variety of potential error-producing factors present in the OR setting. While such factors were viewed by OR staff as occurring infrequently, significant relationships between the estimated frequency of systemic problems and specific error forms were identified. These findings can inform both the development of theoretical models of surgical error, as well as the practice of developing targeted intervention programs.

AbstractBackgroundMany researchers have previously explored the correlation between surgical flow disruptions and adverse events in cardiac surgery; however, there is no reliable tool to prospectively categorize surgical flow disruptions and the conditions that predispose a surgical team to adverse events.MethodsTwo independent raters of different medical and human factors expertise observed 12 cardiovascular operations and iteratively designed a surgical flow disruption tool (SFDT) to characterize surgical flow disruptions and the latent factors that contribute to adverse events. Categories to characterize surgical flow disruptions were created based on human factors models of human error. After the design period, both raters observed ten surgical cases using the tool to assess validity and inter‐rater reliability.ResultsRating agreement (weighted kappa) for each category across the ten surgeries was moderate to very high, resulting in strong inter‐rater reliability for each category on the surgical flow disruption tool. Use of the SFDT was simple and clear for observers of diverse backgrounds, including human factors experts and medical personnel.ConclusionsThis research depicts the development and utility of a tool to analyze surgical flow disruptions in the cardiovascular operating room with satisfactory inter‐rater reliability. This tool is an important first step in systematically categorizing and measuring surgical flow disruptions and their impact on patient safety in the operating room.