메뉴 건너뛰기




Volumn 256, Issue 2, 2012, Pages 203-210

Protecting patients from an unsafe system: The etiology and recovery of intraoperative deviations in care

Author keywords

adverse events; human factors; intraoperative deviations; operating room delays; resilience; surgical safety

Indexed keywords

ADVERSE OUTCOME; ARTICLE; COOPERATION; HEALTH CARE DELIVERY; HUMAN; INTERPERSONAL COMMUNICATION; INTRAOPERATIVE PERIOD; LEADERSHIP; OPERATION DURATION; ORGANIZATIONAL STRUCTURE; PATIENT SAFETY; PRIORITY JOURNAL; THERAPY DELAY; VIDEORECORDING;

EID: 84863856118     PISSN: 00034932     EISSN: 15281140     Source Type: Journal    
DOI: 10.1097/SLA.0b013e3182602564     Document Type: Article
Times cited : (72)

References (49)
  • 1
    • 84873614704 scopus 로고    scopus 로고
    • Accessed 28 April, 2011
    • What is ergonomics? http://www.iea.cc/01-what/What%20is%20Ergonomics. html. Accessed 28 April, 2011.
    • What Is Ergonomics?
  • 2
    • 0034938647 scopus 로고    scopus 로고
    • The human factor in cardiac surgery: Errors and near misses in a high technology medical domain
    • DOI 10.1016/S0003-4975(00)02592-3, PII S0003497500025923
    • Carthey J, de Leval MR, Reason JT. The human factor in cardiac surgery: errors and near misses in a high technology medical domain. Ann Thorac Surg. 2001;72:300-305. (Pubitemid 32643074)
    • (2001) Annals of Thoracic Surgery , vol.72 , Issue.1 , pp. 300-305
    • Carthey, J.1    De Leval, M.R.2    Reason, J.T.3
  • 4
    • 65249101774 scopus 로고    scopus 로고
    • Surgical team behaviors and patient outcomes
    • Mazzocco K, Petitti DB, Fong KT, et al. Surgical team behaviors and patient outcomes. Am J Surg. 2009;197:678-685.
    • (2009) Am J Surg , vol.197 , pp. 678-685
    • Mazzocco, K.1    Petitti, D.B.2    Fong, K.T.3
  • 7
    • 35648995887 scopus 로고    scopus 로고
    • Patterns of technical error among surgical malpractice claims: An analysis of strategies to prevent injury to surgical patients
    • DOI 10.1097/SLA.0b013e31815865f8, PII 0000065820071100000003
    • Regenbogen SE, Greenberg CC, Studdert DM, et al. Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients. Ann Surg. 2007;246:705-711. (Pubitemid 350035643)
    • (2007) Annals of Surgery , vol.246 , Issue.5 , pp. 705-711
    • Regenbogen, S.E.1    Greenberg, C.C.2    Studdert, D.M.3    Lipsitz, S.R.4    Zinner, M.J.5    Gawande, A.A.6
  • 8
    • 83455241413 scopus 로고    scopus 로고
    • The New York model: Root cause analysis driving patient safety initiative to ensure correct surgical and invasive procedures
    • Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Assessment. Rockville, MD: Agency for Healthcare Research and Quality
    • Faltz LL, Morley JN, Flink E, et al. The New York model: root cause analysis driving patient safety initiative to ensure correct surgical and invasive procedures. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol 1: Assessment). Rockville, MD: Agency for Healthcare Research and Quality; 2008.
    • (2008) Advances in Patient Safety: New Directions and Alternative Approaches , vol.1
    • Faltz, L.L.1    Morley, J.N.2    Flink, E.3
  • 9
    • 84855236443 scopus 로고    scopus 로고
    • Preventing wrong site, procedure, and patient events using a common cause analysis
    • Mallett R, Conroy M, Saslaw LZ, et al. Preventing wrong site, procedure, and patient events using a common cause analysis. Am JMed Qual. 2012;27:21-29.
    • (2012) Am JMed Qual , vol.27 , pp. 21-29
    • Mallett, R.1    Conroy, M.2    Saslaw, L.Z.3
  • 11
    • 35548959092 scopus 로고    scopus 로고
    • Disruptions in surgical flow and their relationship to surgical errors: An exploratory investigation
    • DOI 10.1016/j.surg.2007.07.034, PII S0039606007005168
    • Wiegmann DA, ElBardissi AW, Dearani JA, et al. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery. 2007;142:658-665. (Pubitemid 350018854)
    • (2007) Surgery , vol.142 , Issue.5 , pp. 658-665
    • Wiegmann, D.A.1    ElBardissi, A.W.2    Dearani, J.A.3    Daly, R.C.4    Sundt III, T.M.5
  • 12
    • 41149103832 scopus 로고    scopus 로고
    • Teamwork and error in the operating room: Analysis of skills and roles
    • DOI 10.1097/SLA.0b013e3181642ec8, PII 0000065820080400000019
    • Catchpole K, Mishra A, Handa A, et al. Teamwork and error in the operating room: analysis of skills and roles. Ann Surg. 2008;247:699-706. (Pubitemid 351440623)
    • (2008) Annals of Surgery , vol.247 , Issue.4 , pp. 699-706
    • Catchpole, K.1    Mishra, A.2    Handa, A.3    McCulloch, P.4
  • 14
    • 0037333907 scopus 로고    scopus 로고
    • Efficiency of the operating room suite
    • DOI 10.1016/S0002-9610(02)01362-4
    • Weinbroum AA, Ekstein P, Ezri T. Efficiency of the operating room suite. Am J Surg. 2003;185:244-250. (Pubitemid 36298891)
    • (2003) American Journal of Surgery , vol.185 , Issue.3 , pp. 244-250
    • Weinbroum, A.A.1    Ekstein, P.2    Ezri, T.3
  • 15
    • 0036272458 scopus 로고    scopus 로고
    • A systems approach to surgical safety
    • discussion 1015
    • Calland JF, Guerlain S, Adams RB, et al. A systems approach to surgical safety. Surg Endosc. 2002;16:1005-1014; discussion 1015.
    • (2002) Surg Endosc , vol.16 , pp. 1005-1014
    • Calland, J.F.1    Guerlain, S.2    Adams, R.B.3
  • 16
    • 1642412836 scopus 로고    scopus 로고
    • Systems Approaches to Surgical Quality and Safety: From Concept to Measurement
    • DOI 10.1097/01.sla.0000118753.22830.41
    • Vincent C,Moorthy K, Sarker SK, et al. Systems approaches to surgical quality and safety: from concept to measurement. Ann Surg. 2004;239:475-482. (Pubitemid 38372763)
    • (2004) Annals of Surgery , vol.239 , Issue.4 , pp. 475-482
    • Vincent, C.1    Moorthy, K.2    Sarker, S.K.3    Chang, A.4    Darzi, A.W.5
  • 18
    • 36148962824 scopus 로고    scopus 로고
    • Risk-Adjusted Morbidity in Teaching Hospitals Correlates with Reported Levels of Communication and Collaboration on Surgical Teams but Not with Scale Measures of Teamwork Climate, Safety Climate, or Working Conditions
    • DOI 10.1016/j.jamcollsurg.2007.07.039, PII S1072751507013968
    • Davenport DL, Henderson WG, Mosca CL, et al. Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. J Am Coll Surg. 2007;205:778-784. (Pubitemid 350116632)
    • (2007) Journal of the American College of Surgeons , vol.205 , Issue.6 , pp. 778-784
    • Davenport, D.L.1    Henderson, W.G.2    Mosca, C.L.3    Khuri, S.F.4    Mentzer Jr., R.M.5
  • 19
    • 0031977834 scopus 로고    scopus 로고
    • Successful strategies for improving operating room efficiency at academic institutions
    • DOI 10.1097/00000539-199804000-00039
    • Overdyk FJ, Harvey SC, Fishman RL, et al. Successful strategies for improving operating room efficiency at academic institutions. Anesth Analg. 1998;86:896-906. (Pubitemid 28177751)
    • (1998) Anesthesia and Analgesia , vol.86 , Issue.4 , pp. 896-906
    • Overdyk, F.J.1    Harvey, S.C.2    Fishman, R.L.3    Shippey, F.4
  • 20
    • 42949148611 scopus 로고    scopus 로고
    • Durable improvements in efficiency, safety, and satisfaction in the operating room
    • discussion 1089-1090
    • Heslin MJ, Doster BE, Daily SL, et al. Durable improvements in efficiency, safety, and satisfaction in the operating room. J Am Coll Surg. 2008;206:1083-1039; discussion 1089-1090.
    • (2008) J Am Coll Surg , vol.206 , pp. 1083-11039
    • Heslin, M.J.1    Doster, B.E.2    Daily, S.L.3
  • 21
    • 79959494197 scopus 로고    scopus 로고
    • Use of lean and six sigma methodology to improve operating room efficiency in a high-volume tertiarycare academic medical center
    • discussion 93-94
    • Cima RR, Brown MJ, Hebl JR, et al. Use of lean and six sigma methodology to improve operating room efficiency in a high-volume tertiarycare academic medical center. J Am Coll Surg. 2011;213:83-92; discussion 93-94.
    • (2011) J Am Coll Surg , vol.213 , pp. 83-92
    • Cima, R.R.1    Brown, M.J.2    Hebl, J.R.3
  • 22
    • 33744832658 scopus 로고    scopus 로고
    • Measuring intra-operative interference from distraction and interruption observed in the operating theatre
    • DOI 10.1080/00140130600568899, PII V1422861670629, Patient Safety
    • Healey AN, Sevdalis N, Vincent CA. Measuring intra-operative interference from distraction and interruption observed in the operating theatre. Ergonomics. 2006;49:589-604. (Pubitemid 43832380)
    • (2006) Ergonomics , vol.49 , Issue.5-6 , pp. 589-604
    • Healey, A.N.1    Sevdalis, N.2    Vincent, C.A.3
  • 24
    • 65649110471 scopus 로고    scopus 로고
    • Development and validation of the SURgical PAtient Safety System (SURPASS) checklist
    • de Vries EN, Hollmann MW, Smorenburg SM, et al. Development and validation of the SURgical PAtient Safety System (SURPASS) checklist. Qual Saf Health Care. 2009;18:121-126.
    • (2009) Qual Saf Health Care , vol.18 , pp. 121-126
    • De Vries, E.N.1    Hollmann, M.W.2    Smorenburg, S.M.3
  • 25
    • 59449089116 scopus 로고    scopus 로고
    • A surgical safety checklist to reduce morbidity and mortality in a global population
    • Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491-499.
    • (2009) N Engl J Med , vol.360 , pp. 491-499
    • Haynes, A.B.1    Weiser, T.G.2    Berry, W.R.3
  • 27
    • 0004223940 scopus 로고
    • 1st ed.Cambridge,UK: Cambridge University Press
    • Reason JT. Human Error. 1st ed.Cambridge,UK: Cambridge University Press; 1990.
    • (1990) Human Error
    • Reason, J.T.1
  • 28
    • 77951546087 scopus 로고    scopus 로고
    • 1st ed. Burlington, VT: Ashgate Publishing Company
    • Reason JT. The Human Contribution. 1st ed. Burlington, VT: Ashgate Publishing Company; 2008.
    • (2008) The Human Contribution
    • Reason, J.T.1
  • 29
    • 84856428256 scopus 로고    scopus 로고
    • Minding the gaps: Creating resilience in health care
    • Henriksen K, Battles JB, Keyes MA, et al. eds. Performance and Tools. Rockville, MD: Agency for Healthcare Research and Quality
    • Nemeth C, Wears RL, Woods DD, et al. Minding the gaps: creating resilience in health care. In: Henriksen K, Battles JB, Keyes MA, et al. eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol 3: Performance and Tools). Rockville, MD: Agency for Healthcare Research and Quality; 2008.
    • (2008) Advances in Patient Safety: New Directions and Alternative Approaches , vol.3
    • Nemeth, C.1    Wears, R.L.2    Woods, D.D.3
  • 31
    • 34547472180 scopus 로고    scopus 로고
    • Collaborative cross-checking to enhance resilience
    • Patterson ES, Woods DD, Cook RI, et al. Collaborative cross-checking to enhance resilience. Cogn Tech Work. 2007;9:155-162.
    • (2007) Cogn Tech Work , vol.9 , pp. 155-162
    • Patterson, E.S.1    Woods, D.D.2    Cook, R.I.3
  • 33
    • 0036715703 scopus 로고    scopus 로고
    • Improving patient safety by identifying side effects from introducing bar coding in medication administration
    • DOI 10.1197/jamia.M1061
    • Patterson ES, Cook RI, Render ML. Improving patient safety by identifying side effects from introducing bar coding in medication administration. J Am Med Inform Assoc. 2002;9:540-553. (Pubitemid 35024458)
    • (2002) Journal of the American Medical Informatics Association , vol.9 , Issue.5 , pp. 540-553
    • Patterson, E.S.1    Cook, R.I.2    Render, M.L.3
  • 35
    • 33744515914 scopus 로고    scopus 로고
    • Attitudes to teamwork and safety in the operating theatre
    • Flin R, Yule S, McKenzie L, et al. Attitudes to teamwork and safety in the operating theatre. Surgeon. 2006;4:145-151. (Pubitemid 43810894)
    • (2006) Surgeon , vol.4 , Issue.3 , pp. 145-151
    • Flin, R.1    Yule, S.2    McKenzie, L.3    Paterson-Brown, S.4    Maran, N.5
  • 36
    • 0034681797 scopus 로고    scopus 로고
    • Error, stress, and teamwork in medicine and aviation: Cross sectional surveys
    • Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000;320:745-749. (Pubitemid 30179421)
    • (2000) British Medical Journal , vol.320 , Issue.7237 , pp. 745-749
    • Sexton, J.B.1    Thomas, E.J.2    Helmreich, R.L.3
  • 37
    • 73149124275 scopus 로고    scopus 로고
    • Can aviation-based team training elicit sustainable behavioral change?
    • Sax HC, Browne P,Mayewski RJ, et al. Can aviation-based team training elicit sustainable behavioral change? Arch Surg. 2009;144:1133-1137.
    • (2009) Arch Surg , vol.144 , pp. 1133-1137
    • Sax, H.C.1    Browne, P.2    Mayewski, R.J.3
  • 38
    • 65649117805 scopus 로고    scopus 로고
    • The effects of aviation-style nontechnical skills training on technical performance and outcome in the operating theatre
    • McCulloch P, Mishra A, Handa A, et al. The effects of aviation-style nontechnical skills training on technical performance and outcome in the operating theatre. Qual Saf Health Care. 2009;18:109-115.
    • (2009) Qual Saf Health Care , vol.18 , pp. 109-115
    • McCulloch, P.1    Mishra, A.2    Handa, A.3
  • 41
    • 77956203424 scopus 로고    scopus 로고
    • The efficacy of medical team training: Improved team performance and decreased operating room delays: A detailed analysis of 4863 cases
    • discussion 483-485
    • Wolf FA,Way LW, Stewart L. The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases. Ann Surg. 2010;252:477-483; discussion 483-485.
    • (2010) Ann Surg , vol.252 , pp. 477-483
    • Wolf, F.A.1    Way, L.W.2    Stewart, L.3
  • 42
    • 52449085603 scopus 로고    scopus 로고
    • Violations of behavioral practices revealed in closed claims reviews
    • Griffen FD, Stephens LS,Alexander JB, et al.Violations of behavioral practices revealed in closed claims reviews. Ann Surg. 2008;248:468-474.
    • (2008) Ann Surg , vol.248 , pp. 468-474
    • Griffen, F.D.1    Stephens, L.S.2    Alexander, J.B.3
  • 43
    • 79251648708 scopus 로고    scopus 로고
    • Observational teamwork assessment for surgery: Content validation and tool refinement
    • Hull L, Arora S, Kassab E, et al. Observational teamwork assessment for surgery: content validation and tool refinement. J AmColl Surg. 2011;212:234-243.e1-e5.
    • (2011) J AmColl Surg , vol.212
    • Hull, L.1    Arora, S.2    Kassab, E.3
  • 44
    • 67649235806 scopus 로고    scopus 로고
    • Observational teamwork assessment for surgery: Construct validation with expert versus novice raters
    • Sevdalis N, Lyons M, Healey AN, et al. Observational teamwork assessment for surgery: construct validation with expert versus novice raters. Ann Surg. 2009;249:1047-1051.
    • (2009) Ann Surg , vol.249 , pp. 1047-1051
    • Sevdalis, N.1    Lyons, M.2    Healey, A.N.3
  • 45
    • 65649105831 scopus 로고    scopus 로고
    • The Oxford NOTECHS System: Reliability and validity of a tool for measuring teamwork behaviour in the operating theatre
    • Mishra A, Catchpole K, McCulloch P. The Oxford NOTECHS System: reliability and validity of a tool for measuring teamwork behaviour in the operating theatre. Qual Saf Health Care. 2009;18:104-108.
    • (2009) Qual Saf Health Care , vol.18 , pp. 104-108
    • Mishra, A.1    Catchpole, K.2    McCulloch, P.3
  • 46
    • 48549103054 scopus 로고    scopus 로고
    • Annoyances, disruptions, and interruptions in surgery: The Disruptions in Surgery Index (DiSI)
    • Sevdalis N, Forrest D, Undre S, et al. Annoyances, disruptions, and interruptions in surgery: the Disruptions in Surgery Index (DiSI). World J Surg. 2008;32:1643-1650.
    • (2008) World J Surg , vol.32 , pp. 1643-1650
    • Sevdalis, N.1    Forrest, D.2    Undre, S.3
  • 48
    • 47749112823 scopus 로고    scopus 로고
    • Risk, human error, and system resilience: Fundamental ideas
    • DOI 10.1518/001872008X250773
    • Sheridan TB. Risk, human error, and system resilience: fundamental ideas. Hum Factors. 2008;50:418-426. (Pubitemid 352029800)
    • (2008) Human Factors , vol.50 , Issue.3 , pp. 418-426
    • Sheridan, T.B.1
  • 49
    • 33748306095 scopus 로고    scopus 로고
    • Three key levers for achieving resilience in medication delivery with information technology
    • Patterson ES, Woods DD, Roth EM, et al. Three key levers for achieving resilience in medication delivery with information technology. J Patient Saf. 2006;2:33-38.
    • (2006) J Patient Saf , vol.2 , pp. 33-38
    • Patterson, E.S.1    Woods, D.D.2    Roth, E.M.3


* 이 정보는 Elsevier사의 SCOPUS DB에서 KISTI가 분석하여 추출한 것입니다.