A human factors approach to understanding patient safety during pediatric cardiac surgery

Understanding the complexity of redesigning care around the clinical microsystem

“…We combined detailed walk-throughs, focused interviews, and task analysis to better understand the process. 34 The process maps are shown in figs 3-5. Several questions are helpful when analyzing a process map to generate improvement ideas: N What are the work-arounds to the proscribed process?…”

A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes

“…Hence, our definition was expanded to include elements of a normative task analysis we conducted using process mapping specifying the norms and tasks of each operation 27 28. Given the relative frequency of events such as, equipment problems and mask violations, these events cannot be regarded as ‘unusual’.…”

Assessing and improving teamwork in cardiac surgery

“…In our study, training for the two observers included in-depth directed study of cardiac surgery theory and literature, watching videotaped paediatric cardiac surgery procedures, and detailed discussions of ethnographic observational methods 6 12. The observers were encouraged to ask questions, and were informally tested by paediatric cardiac surgeons, cardiac anaesthesiologists, cardiac perfusionists and OR nurses to ascertain the observer's knowledge and understanding of procedures and operating room dynamics and culture.…”

“…Breakdowns in teamwork in the operating room may lead to errors10 and poor outcomes 11. Technical skills are fundamental to good outcomes but non-technical factors also impact significantly on individual and team performance and patient outcomes 12. Observing and assessing teamwork in situ is therefore desirable to derive interventions to overcome deficiencies in teamwork and improve outcomes.…”