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Protecting Patients From an Unsafe System: The Etiology and Recovery of Intraoperative Deviations in Care

Hu, Yue-Yung MD, MPH; Arriaga, Alexander F. MD, MPH; Roth, Emilie M. PhD; Peyre, Sarah E. EdD; Corso, Katherine A. MPH; Swanson, Richard S. MD; Osteen, Robert T. MD; Schmitt, Pamela RN, MS, CNOR, CNE; Bader, Angela M. MD, MPH; Zinner, Michael J. MD; Greenberg, Caprice C. MD, MPH

doi: 10.1097/SLA.0b013e3182602564

Objective: To understand the etiology and resolution of unanticipated events in the operating room (OR).

Background: The majority of surgical adverse events occur intraoperatively. The OR represents a complex, high-risk system. The influence of different human, team, and organizational/environmental factors on safety and performance is unknown.

Methods: We video-recorded and transcribed 10 high-acuity operations, representing 43.7 hours of patient care. Deviations, defined as delays and/or episodes of decreased patient safety, were identified by majority consensus of a multidisciplinary team. Factors that contributed to each event and/or mitigated its impact were determined and attributed to the patient, providers, or environment/organization.

Results: Thirty-three deviations (10 delays, 17 safety compromises, 6 both) occurred—with a mean of 1 every 79.4 minutes. These deviations were multifactorial (mean 3.1 factors). Problems with communication and organizational structure appeared repeatedly at the root of both types of deviations. Delays tended to be resolved with vigilance, communication, coordination, and cooperation, while mediation of safety compromises was most frequently accomplished with vigilance, leadership, communication, and/or coordination. The organization/environment was not found to play a direct role in compensation.

Conclusions: Unanticipated events are common in the OR. Deviations result from poor organizational/environmental design and suboptimal team dynamics, with caregivers compensating to avoid patient harm. Although recognized in other high-risk domains, such human resilience has not yet been described in surgery and has major implications for the design of safety interventions.

Unanticipated events are common in the operating room. Deviations result from poor system design and suboptimal team dynamics, with caregivers compensating to avoid patient harm. These results underscore the need for system redesign and team training to improve patient safety.

*Center for Surgery and Public Health

STRATUS Center for Medical Simulation

Department of Surgery

§Department of Operating Room Administration

Department of Anesthesiology, Brigham and Women's Hospital, Boston, MA

Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA

#Department of Health Policy and Management, Harvard School of Public Health, Boston, MA

**Roth Cognitive Engineering, Brookline, MA

††Department of Surgery, University of Rochester, Rochester, NY

‡‡Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI.

Reprints: Caprice C. Greenberg, MD, MPH, Surgical Outcomes Research Program, University of Wisconsin Hospitals and Clinics, 600 Highland Ave H4/730, Madison, WI 53792. E-mail:

Disclosure: This study has been supported by grants from the Risk Management Foundation of the Harvard Medical Institutions, The Rx Foundation, and the National Institutes of Health (Research Training in Alimentary Tract Surgery, 2T32DK00754-12; NIH Loan Repayment Program, L30RR031458-01 and L30CA123695-03). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

Presented at the Quality, Outcomes, and Costs II session of the Surgical Forum at the 2011 American College of Surgeons Clinical Congress; October 23 to 27, 2011; San Francisco, CA.

Copyright © 2012 Wolters Kluwer Health, Inc. All rights reserved.