title: Capturing intraoperative process deviations using a direct observational approach: the glitch method.
abstract: OBJECTIVE
  To develop a sensitive, reliable tool for enumerating and evaluating technical process imperfections during surgical operations.
  
  
  METHODS
  Prospective cohort study with direct observation.
  
  
  METHODS
  Operating theatres on five sites in three National Health Service Trusts.
  
  
  METHODS
  Staff taking part in elective and emergency surgical procedures in orthopaedics, trauma, vascular and plastic surgery; including anaesthetists, surgeons, nurses and operating department practitioners.
  
  
  METHODS
  Reliability and validity of the glitch count method; frequency, type, temporal pattern and rate of glitches in relation to site and surgical specialty.
  
  
  RESULTS
  The glitch count has construct and face validity, and category agreement between observers is good (κ=0.7). Redundancy between pairs of observers significantly improves the sensitivity over a single observation. In total, 429 operations were observed and 5742 glitches were recorded (mean 14 per operation, range 0-83). Specialty-specific glitch rates varied from 6.9 to 8.3/h of operating (ns). The distribution of glitch categories was strikingly similar across specialties, with distractions the commonest type in all cases. The difference in glitch rate between specialty teams operating at different sites was larger than that between specialties (range 6.3-10.5/h, p<0.001). Forty per cent of glitches occurred in the first quarter of an operation, and only 10% occurred in the final quarter.
  
  
  CONCLUSIONS
  The glitch method allows collection of a rich dataset suitable for analysing the changes following interventions to improve process safety, and appears reliable and sensitive. Glitches occur more frequently in the early stages of an operation. Hospital environment, culture and work systems may influence the operative process more strongly than the specialty.
authors.affiliation: Quality, Reliability, Safety and Teamwork Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
authors.forename: Lauren
authors.initials: L
authors.lastname: Morgan
authors.forename: Eleanor
authors.initials: E
authors.lastname: Robertson
authors.forename: Mohammed
authors.initials: M
authors.lastname: Hadi
authors.forename: Ken
authors.initials: K
authors.lastname: Catchpole
authors.forename: Sharon
authors.initials: S
authors.lastname: Pickering
authors.forename: Steve
authors.initials: S
authors.lastname: New
authors.forename: Gary
authors.initials: G
authors.lastname: Collins
authors.forename: Peter
authors.initials: P
authors.lastname: McCulloch
keywords: SURGERY; patient safety; process of care; quality improvement