Learning in a new cardiac surgical center: An analysis of precursor events

Surgery

Volumn 145, Issue 2, 2009, Pages 131-137

  Wong, Daniel R ^a   Ali, Imtiaz S ^a   Torchiana, David F ^b   Agnihotri, Arvind K ^b   Bohmer, Richard M J ^c   Vander Salm, Thomas J ^d  

^a Maritime Heart Centre   (Canada)

^b MASSACHUSETTS GENERAL HOSPITAL   (United States)

^c HARVARD BUSINESS SCHOOL   (United States)

^d NORTH SHORE MEDICAL CENTER   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ADULT; ARTICLE; CONTROLLED STUDY; CORONARY ARTERY BYPASS GRAFT; HOSPITAL DEPARTMENT; HUMAN; INTRAOPERATIVE PERIOD; MAJOR CLINICAL STUDY; MORTALITY; OUTCOME ASSESSMENT; POSTOPERATIVE PERIOD; PRIORITY JOURNAL;

CARDIAC SURGICAL PROCEDURES; CARDIOLOGY SERVICE, HOSPITAL; HUMANS; MEDICAL ERRORS; OUTCOME ASSESSMENT (HEALTH CARE); PROCESS ASSESSMENT (HEALTH CARE); PROSPECTIVE STUDIES; TIME FACTORS;

EID: 58349107915     PISSN: 00396060     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.surg.2008.09.009     Document Type: Article

References (19)

1. Spear S.J. Learning to lead at Toyota. Harvard Business Rev 82 (2004) 78-86 151
2. Womack J.P., Jones D.T., and Roos D. The machine that changed the world: based on the Massachusetts Institute of Technology 5 million dollar 5-year study on the future of the automobile (1990), Rawson Associates, New York
3. Novick R.J., Fox S.A., Stitt L.W., Kiaii B.B., Swinamer S.A., Rayman R., et al. Assessing the learning curve in off-pump coronary artery surgery via CUSUM failure analysis. Ann Thorac Surg 73 (2002) S358-S362
4. Novick R.J., and Stitt L.W. The learning curve of an academic cardiac surgeon: use of the CUSUM method. J Card Surg 14 (1999) 312-320
5. Bier V.M., Kunreuther H., and Phimister J.R. Accident precursor analysis and management: reducing technological risk through diligence (2004), National Academies Press, Washington, DC
6. Wong D.R., Vander Salm T.J., Ali I.S., Agnihotri A.K., Bohmer R.M., and Torchiana D.F. Prospective assessment of intraoperative precursor events during cardiac surgery. Eur J Cardiothorac Surg 29 (2006) 447-455
7. Reason J.T. Human error (1990), Cambridge University Press, Cambridge (England)
8. de Leval M.R., Carthey J., Wright D.J., Farewell V.T., and Reason J.T. Human factors and cardiac surgery: a multicenter study. J Thorac Cardiovasc Surg 119 (2000) 661-672
9. Wong D.R., Torchiana D.F., Vander Salm T.J., Agnihotri A.K., Bohmer R.M., and Ali I.S. Impact of cardiac surgical intraoperative precursor events on adverse outcomes. Surgery 141 (2007) 715-722
10. Donabedian A. Evaluating the quality of medical care. Milbank Memorial Fund Quarterly 44 (1966) 166-206
11. de Leval M.R., Francois K., Bull C., Brawn W., and Spiegelhalter D. Analysis of a cluster of surgical failures. Application to a series of neonatal arterial switch operations. J Thorac Cardiovasc Surg 107 (1994) 914-923
12. Pisano G.P., Bohmer R.M.J., and Edmondson A.C. Organizational differences in rates of learning: evidence from the adoption of minimally invasive cardiac surgery. Manag Sci 47 (2001) 752-768
13. de Leval M.R. Beyond flatland. J Thorac Cardiovasc Surg 125 (2003) 12-19
14. Argyris C., and Schön D.A. Theory in practice: increasing professional effectiveness. 1st ed. (1974), Jossey-Bass Publishers, San Francisco
15. Tucker A.L., Edmondson A.C., and Spear S. When problem solving prevents organizational learning. J Organizational Change Manag 15 (2002) 122-137
16. Edmondson A., and Bohmer Rm G.P. Speeding up team learning. Harvard Business Rev 79 (2001) 125-134
17. Michaelsen L., and Richards B. Drawing conclusions from the team-learning literature in health-sciences education: a commentary. Teaching and learning in medicine. Winter 17 (2005) 85-88
18. Michaelsen LK. Getting started with team-based learning. Available from: http://www.teambasedlearning.org.
19. Chang A., Schyve P.M., Croteau R.J., O'Leary D.S., and Loeb J.M. The JCAHO patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events. Int J Qual Health Care 17 (2005) 95-105