title: Human factors and cardiac surgery: a multicenter study.
abstract: OBJECTIVE
  To study the role of human factors on surgical outcomes, with a series of 243 arterial switch operations performed by 21 surgeons taken as a model.
  
  
  METHODS
  The following data were collected: patient-specific and procedural variables, self-assessment questionnaires, and a written report from a human factors researcher who observed the operation. The relationship of patient-specific variables to outcomes (death and death and/or near miss) was used to develop a multivariable baseline model to analyze the role of human factors after adjustment for these variables.
  
  
  RESULTS
  The overall mortality was 6.6% with 24.3% of cases resulting in death and death and/or near misses. The self-assessment questionnaires were found to be unhelpful. Major and minor human failures were extracted from the written report. Major negative events were potentially life-threatening failures, whereas minor events were failures that, in isolation, were not expected to have serious consequences. Major events were closely related to death (P <.001) and death and/or near misses (P <.001). Appropriate compensation, however, sharply reduced the risk of death (P =.003). The total number of minor events was also closely related to both death and death and/or near misses (P <.001).
  
  
  CONCLUSIONS
  The study highlights the role of human factors in negative surgical outcomes. Even in the most eventful circumstances, however, appropriate human factors defense mechanisms can lead to a successful outcome.
authors.affiliation: Great Ormond Street Hospital for Children NHS Trust, London, UK.
authors.forename: M R
authors.initials: MR
authors.lastname: de Leval
authors.forename: J
authors.initials: J
authors.lastname: Carthey
authors.forename: D J
authors.initials: DJ
authors.lastname: Wright
authors.forename: V T
authors.initials: VT
authors.lastname: Farewell
authors.forename: J T
authors.initials: JT
authors.lastname: Reason
mesh_terms: D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006345:Heart Septal Defects, Ventricular / Q000401:mortality / Q000601:surgery*; D006801:Humans; D007231:Infant, Newborn; D016015:Logistic Models; D008297:Male; D019300:Medical Errors; D011183:Postoperative Complications; D012307:Risk Factors; D014188:Transposition of Great Vessels / Q000401:mortality / Q000601:surgery*; D016896:Treatment Outcome