title: Identification of systems failures in successful paediatric cardiac surgery.
abstract: Patient safety will benefit from an approach to human error that examines systemic causes, rather than blames individuals. This study describes a direct observation methodology, based on a threat and error model, prospectively to identify types and sources of systems failures in paediatric cardiac surgery. Of substantive interest were the range, frequency and types of failures that could be identified and whether minor failures could accumulate to form more serious events, as has been the case in other industries. Check lists, notes and video recordings were employed to observe 24 successful operations. A total of 366 failures were recorded. Coordination and communication problems, equipment problems, a relaxed safety culture, patient-related problems and perfusion-related problems were most frequent, with a smaller number of skill, knowledge and decision-making failures. Longer and more risky operations were likely to generate a greater number of minor failures than shorter and lower risk operations, and in seven higher-risk cases frequently occurring minor failures accumulated to threaten the safety of the patient. Non-technical errors were more prevalent than technical errors and task threats were the most prevalent systemic source of error. Adverse events in surgery are likely to be associated with a number of recurring and prospectively identifiable errors. These may be co-incident and cumulative human errors predisposed by threats embedded in the system, rather than due to individual incompetence or negligence. Prospectively identifying and reducing these recurrent failures would lead to improved surgical standards and enhanced patient safety.
authors.affiliation: Royal College of Surgeons of England, Lincoln's Inn Fields, London, WC2A 3PE, UK. ken.catchpole@nds.ox.ac.uk
authors.forename: K R
authors.initials: KR
authors.lastname: Catchpole
authors.forename: A E B
authors.initials: AE
authors.lastname: Giddings
authors.forename: M R
authors.initials: MR
authors.lastname: de Leval
authors.forename: G J
authors.initials: GJ
authors.lastname: Peek
authors.forename: P J
authors.initials: PJ
authors.lastname: Godden
authors.forename: M
authors.initials: M
authors.lastname: Utley
authors.forename: S
authors.initials: S
authors.lastname: Gallivan
authors.forename: G
authors.initials: G
authors.lastname: Hirst
authors.forename: T
authors.initials: T
authors.lastname: Dale
mesh_terms: D000293:Adolescent; D002648:Child; D006804:Ergonomics; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D009873:Operating Rooms / Q000592:standards*; D010372:Pediatrics / Q000592:standards*; D019990:Perioperative Care / Q000009:adverse effects / Q000592:standards; D011183:Postoperative Complications / Q000517:prevention & control; D018570:Risk Assessment; D012308:Risk Management; D017751:Safety Management / Q000379:methods*; D013043:Specialties, Surgical / Q000592:standards*; D013597:Systems Analysis; D013647:Task Performance and Analysis; D013903:Thoracic Surgery / Q000592:standards*; D016896:Treatment Outcome; D006113:United Kingdom