Task, team and technology integration in the paediatric cardiac operating room

One of the most potentially valuable paradigms for improving safety in surgery is known as human factors. However, the main use of this approach has been largely limited to aviation-style teamwork training. In this paper two case studies are presented that illustrate the complex interactions between team, task and technology in paediatric cardiac surgery. Both illustrate primarily how the technological co-ordination of the perfusion task is shared amongst the three key team members. The first case study presents two approaches to going onto cardio-pulmonary bypass, one of which demonstrates a range of key risks. The second presents the transcripts of a case of mild exsanguinations that was quickly recovered from. This case illustrates both the complexity of error and the importance of task-based communications for error capture and recovery. The discussion argues for a broader approach to teamwork considerations in the OR.