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

Pediatric cardiac surgery-a highly complex, low-error-tolerant field with patients who are normally sick and require complex corrections at a very early age-has long recognized the need to study human factors and their relationship to medical outcomes. The current study uses a multidisciplinary pediatric cardiac team at a high-volume institution (>300 cases per year) to study patient safety practices using human factors methods including a retrospective chart review, safety culture analysis, and observations of the team in the operating room. Preliminary results from observations include examples of major and minor events (ranked by potential patient consequences) compensated or uncompensated by clinical responses to such events, active and/or latent communication break-downs, and internal and external distractions. The culture of care was felt by the providers to be adequate and safety was not felt to be a problem despite the adverse events noted. Major events occurred most frequently during surgical correction and/or bypass run (N=16) and post-bypass period (N=17). Minor events occurred most frequently during the anesthesia period (N=46) and during surgical correction and/or bypass run (N=63). Internal and external distractions occurred most frequently during the surgical correction and/or bypass run (N=167). The majority of clinical responses to problematic events observed occurred as a result of cognitive recognition by practitioners. There were no intra-operative deaths observed. No-harm events, near misses, and adverse events were observed and examples are provided. Future directions include linking observations to medical outcomes, video-recording operations to analyze technical adverse events or near misses, and surveying team members of major and minor events and clinical responses to these events.