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A Theoretical Model of Flow Disruptions for the Anesthesia Team During Cardiovascular Surgery

Boquet, Albert PhD*; Cohen, Tara PhD*; Diljohn, Fawaaz MS*; Cabrera, Jennifer MS*; Reeves, Scott MD; Shappell, Scott PhD*

doi: 10.1097/PTS.0000000000000406
Original Article: PDF Only

Objectives This investigation explores flow disruptions observed during cardiothoracic surgery and how they serve to disconnect anesthesia providers from their primary task. We can improve our understanding of this disengagement by exploring what we call the error space or the accumulated time required to resolve disruptions.

Methods Trained human factors students observed 10 cardiac procedures for disruptions impacting the anesthesia team and recorded the time required to resolve these events. Observations were classified using a human factors taxonomy.

Results Of 301 disruptions observed, interruptions (e.g., those events related to alerts, distractions, searching activity, spilling/dropping, teaching moment, and task deviations) accounted for the greatest frequency of events (39.20%). The average amount of time needed for each disruption to be resolved was 48 seconds. Across 49.87 hours of observation, more than 4 hours were spent resolving disruptions to the anesthesia team's work flow.

Conclusions By defining a calculable error space associated with these disruptions, this research provides a conceptual metric that can serve in the identification and design of targeted interventions. This method serves as a proactive approach for recognizing systemic threats, affording healthcare workers the opportunity to mitigate the development and incidence of preventable errors precedently.

From the *Embry-Riddle Aeronautical University, Daytona Beach, Florida; and †Medical University of South Carolina, Charleston, South Carolina.

Correspondence: Tara N. Cohen, PhD, 600 S Clyde Morris Blvd, Daytona Beach, FL 32114 (e-mail:

The authors disclose no conflict of interest.

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