title: Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room.
abstract: BACKGROUND
  Cardiac surgical procedures are complex and require the coordinated action of many. This creates the potential for small failures that could be the substrate for subsequent morbidity or mortality. High-reliability science suggests that preoccupation with small failures can lead to improved outcomes.
  
  
  METHODS
  Failures of all magnitudes (ie, events) were captured within the pediatric cardiac operating room starting with a single surgeon in April 2008. As the surgical team became more familiar with the process, failure recording was extended to all surgeons and all surgical procedures performed until the conclusion of the study in December 2010. New recording processes were developed and used on a rolling basis during this study.
  
  
  RESULTS
  With systematic capture, event rates increased (from occurring within 20% to 50% of operative procedures). Although we identified 9 recurrent patterns, 2 categories (ie, Equipment and Patient Instability) accounted for almost half of the events (45%). The greatest number of events occurred during the prebypass period (40.2%), compared with bypass (20.1%) and postbypass (32.3%) periods. These events were mainly difficulties in access (31.8%), equipment (42.4%), and patient instability (33.3%) in each of the epochs, respectively. Of all events, 7.3% occurred during nonbypass cases, 30.6% of these were communication events. Implementation of this initiative led to recognition of major system-wide issues (eg, need for change in the blood-product acquisition process).
  
  
  CONCLUSIONS
  Preoccupation with all failures in the operating room can reveal important information about the operating room and perioperative microenvironment that can prompt substantive process changes both locally and within the larger health system.
authors.affiliation: Section of Pediatric Cardiothoracic Surgery, Washington University School of Medicine, St Louis Children's Hospital, St Louis, MO.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Bowermaster
authors.affiliation: Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
authors.forename: Megan
authors.initials: M
authors.lastname: Miller
authors.affiliation: Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
authors.forename: Traci
authors.initials: T
authors.lastname: Ashcraft
authors.affiliation: Section of Pediatric Cardiothoracic Surgery, Washington University School of Medicine, St Louis Children's Hospital, St Louis, MO.
authors.forename: Michael
authors.initials: M
authors.lastname: Boyd
authors.affiliation: Section of Pediatric Cardiothoracic Surgery, Washington University School of Medicine, St Louis Children's Hospital, St Louis, MO.
authors.forename: Anoop
authors.initials: A
authors.lastname: Brar
authors.affiliation: Section of Pediatric Cardiothoracic Surgery, Washington University School of Medicine, St Louis Children's Hospital, St Louis, MO.
authors.forename: Peter
authors.initials: P
authors.lastname: Manning
authors.affiliation: Section of Pediatric Cardiothoracic Surgery, Washington University School of Medicine, St Louis Children's Hospital, St Louis, MO. Electronic address: eghtesadyp@wudosis.wustl.edu.
authors.forename: Pirooz
authors.initials: P
authors.lastname: Eghtesady
mesh_terms: D006348:Cardiac Surgical Procedures / Q000592:standards*; D002648:Child; D003142:Communication; D003625:Data Collection / Q000379:methods* / Q000592:standards; D004282:Documentation / Q000379:methods* / Q000592:standards; D006801:Humans; D007400:Interprofessional Relations; D019300:Medical Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D010348:Patient Care Team; D010372:Pediatrics; D017064:Process Assessment, Health Care / Q000379:methods; D011785:Quality Assurance, Health Care / Q000379:methods*; D058996:Quality Improvement