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.

Keywords:

• Error
• Surgery
• Observation
• Health care
• Safety

Acknowledgements

This project was funded by the Department of Health and the National Patient Safety Agency. We would like to extend our thanks to the patients and their parents for allowing us to involve them in our studies and to the staff participants who allowed us to observe and video them at work. We are also grateful to our reviewers for providing helpful comments on earlier drafts of this paper. Research at the Institute of Child Health and Great Ormond Street Hospital for Children NHS Trust benefits from research and development funding received from the NHS Executive.