title: A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes.
abstract: OBJECTIVE
  Paediatric cardiac surgery has a low error tolerance and demands high levels of cognitive and technical performance. Growing evidence suggests that further improvements in patient outcomes depend on system factors, in particular, effective team skills. The hypotheses that small intraoperative non-routine events (NREs) can escalate to more serious situations and that effective teamwork can prevent the development of serious situations were examined to develop a method to assess these skills and to provide evidence for improvements in training and performance.
  
  
  METHODS
  This mixed-method design, using both quantitative and qualitative measures, relied on trained human factor observers who observed and coded NREs and teamwork elements from the time of patient arrival into the operating room to patient handover to the intensive care unit. Real-time teamwork observations were coupled with microsystem preparedness measures, operative duration, assessed difficulty of the operation and patient outcome measures. Behaviour was rated based on whether it hindered or enhanced teamwork.
  
  
  RESULTS
  40 paediatric cardiac surgery cases were observed. Surgeons displayed better teamwork during complicated procedures, particularly during the surgical bypass/repair epoch. More procedural NREs were associated with a more complicated postoperative course (M(uncomplicated)=9.08; M(minor complications)=11.11; M(major morbidity)=14.60, F(2,26)=3.46, p<0.05). Procedural NREs decreased substantially over time (M₁=13.5; M₂=7.1, F(1,37)=33.07, p<0.001).
  
  
  CONCLUSIONS
  Structured observation of effective teamwork in the operating room can identify substantive deficiencies in the system and conduct of procedures, even in otherwise successful operations. High performing teams are more resilient displaying effective teamwork when operations become more difficult.
authors.affiliation: TNO Human Factors, 3769 ZG Soesterberg, The Netherlands. jan_maarten.schraagen@tno.nl
authors.forename: Jan Maarten
authors.initials: JM
authors.lastname: Schraagen
authors.forename: Ton
authors.initials: T
authors.lastname: Schouten
authors.forename: Meike
authors.initials: M
authors.lastname: Smit
authors.forename: Felix
authors.initials: F
authors.lastname: Haas
authors.forename: Dolf
authors.initials: D
authors.lastname: van der Beek
authors.forename: Josine
authors.initials: J
authors.lastname: van de Ven
authors.forename: Paul
authors.initials: P
authors.lastname: Barach
mesh_terms: D006348:Cardiac Surgical Procedures; D002983:Clinical Competence; D006801:Humans; D007400:Interprofessional Relations; D010348:Patient Care Team / Q000458:organization & administration*; D010372:Pediatrics; D011446:Prospective Studies; D011787:Quality of Health Care / Q000458:organization & administration*; D016896:Treatment Outcome