+1 Recommend
1 collections
      • Record: found
      • Abstract: found
      • Conference Proceedings: found
      Is Open Access

      Teams and Cardiac Surgery

      , , ,

      9th Bi-annual International Conference on Naturalistic Decision Making (NDM9) (NDM)

      Naturalistic Decision Making (NDM9)

      23 - 26 June 2009

      Medical errors, patient safety, medical teams

      Read this article at

          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.


          Motivation – Our study is designed to identify human factors that are a threat to the safety of children with heart disease. Research approach – After an initial observation period, we will apply a major safety intervention. We will then re-measure the occurrence and types of human factors in the operating room, and the incidence of adverse events, near misses and hospital death, to evaluate if there was a significant post-intervention reduction. Findings/design – We focus on challenges encountered during the training of the observers. Research Limitations – Because of the complexity of the OR, observations are necessarily subjective. Originality/Value – This work is original because of the systematic evaluation of a safety intevention and the training protocol for the observers. Take Away Message – Systematic and periodic assessment of observers is required when teamwork is observed in complex, dynamic settings.

          Related collections

          Most cited references 24

          • Record: found
          • Abstract: not found
          • Article: not found

          On error management: lessons from aviation.

           R Helmreich (2000)
            • Record: found
            • Abstract: found
            • Article: not found

            A look into the nature and causes of human errors in the intensive care unit.

             R Pizov,  C Sprung,  Y Donchin (1995)
            The purpose of this study was to investigate the nature and causes of human errors in the intensive care unit (ICU), adopting approaches proposed by human factors engineering. The basic assumption was that errors occur and follow a pattern that can be uncovered. Concurrent incident study. Medical-surgical ICU of a university hospital. Two types of data were collected: errors reported by physicians and nurses immediately after an error discovery; and activity profiles based on 24-hr records taken by observers with human engineering experience on a sample of patients. During the 4 months of data collection, a total of 554 human errors were reported by the medical staff. Errors were rated for severity and classified according to the body system and type of medical activity involved. There was an average of 178 activities per patient per day and an estimated number of 1.7 errors per patient per day. For the ICU as a whole, a severe or potentially detrimental error occurred on the average twice a day. Physicians and nurses were about equal contributors to the number of errors, although nurses had many more activities per day. A significant number of dangerous human errors occur in the ICU. Many of these errors could be attributed to problems of communication between the physicians and nurses. Applying human factor engineering concepts to the study of the weak points of a specific ICU may help to reduce the number of errors. Errors should not be considered as an incurable disease, but rather as preventable phenomena.
              • Record: found
              • Abstract: found
              • Article: not found

              Non-technical skills for surgeons in the operating room: a review of the literature.

              This review examines the surgical and psychological literature on surgeons' intraoperative non-technical skills. These are the critical cognitive and interpersonal skills that complement surgeons' technical abilities. The objectives of this paper are (1) to identify the non-technical skills required by surgeons in the operating room and (2) assess the behavioral marker systems that have been developed for rating surgeons' non-technical skills. A literature search was conducted against a set of inclusion criteria. Databases searched included BioMed Central, Medline, EDINA BIOSIS, Web-of-Knowledge, PsychLit, and ScienceDirect. A number of "core" categories of non-technical skills were identified from 4 sources of data: questionnaire and interview studies, observational studies, adverse event analyses, and the surgical education/competence assessment literature. The main skill categories were communication, teamwork, leadership, and decision making. The existing frameworks used to measure surgeons' non-technical skills were found to be deficient in terms of either their psychometric properties or suitability for rating the full range of skills in individual surgeons. Further work is required to develop a valid taxonomy of individual surgeons' non-technical skills for training and feedback.

                Author and article information

                June 2009
                June 2009
                : 152-159
                TNO Human Factors
                New South Wales Injury Risk Management Center
                TNO Quality of Life
                © Jan Maarten Schraagen et al. Published by BCS Learning and Development Ltd. 9th Bi-annual International Conference on Naturalistic Decision Making (NDM9), BCS London

                This work is licensed under a Creative Commons Attribution 4.0 Unported License. To view a copy of this license, visit

                9th Bi-annual International Conference on Naturalistic Decision Making (NDM9)
                BCS London
                23 - 26 June 2009
                Electronic Workshops in Computing (eWiC)
                Naturalistic Decision Making (NDM9)
                Product Information: 1477-9358BCS Learning & Development
                Self URI (journal page):
                Electronic Workshops in Computing


                Comment on this article