Patient Safety Science in Cardiothoracic Surgery: An Overview

Annals of Thoracic Surgery

Volumn 101, Issue 2, 2016, Pages 426-433

  Sanchez, Juan A ^a   Ferdinand, Francis D ^b   Fann, James I ^c  

^a JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE   (United States)

^b THOMAS JEFFERSON UNIVERSITY   (United States)

^c STANFORD UNIVERSITY MEDICAL CENTER   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ADVERSE OUTCOME; ARTICLE; CULTURAL ANTHROPOLOGY; HUMAN; INTERPERSONAL COMMUNICATION; MEDICAL INFORMATION; MEDICAL SOCIETY; PATIENT SAFETY; PRIORITY JOURNAL; SCIENCE IN GENERAL; TEAMWORK; THORAX SURGERY; TREATMENT FAILURE; ADVERSE EFFECTS; COOPERATION; POSTOPERATIVE COMPLICATIONS; STANDARDS;

COMMUNICATION; COOPERATIVE BEHAVIOR; HUMANS; PATIENT SAFETY; POSTOPERATIVE COMPLICATIONS; THORACIC SURGICAL PROCEDURES;

EID: 84951868191     PISSN: 00034975     EISSN: 15526259     Source Type: Journal    
DOI: 10.1016/j.athoracsur.2015.12.034     Document Type: Article

References (39)

1. 1 Grover, F.L., Shahian, D.M., Clark, R.E., Edwards, F.H., The STS national database. Ann Thorac Surg 97 (2014), S48–54.
2. 2 Clancy, C.M., Ten years after To Err Is Human. Am J Med Qual 24 (2009), 525–528.
3. 3 Gawande, A.A., Thomas, E.J., Zinner, M.J., Brennan, T.A., The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery 126 (1999), 66–75.
4. 4 Martinez, E.A., Shore, A., Colantuoni, E., et al. Cardiac surgery errors: results from the UK national reporting and learning system. Int J Qual Health Care 23 (2011), 151–158.
5. 5 Gurses, A.P., Kim, G., Martinez, E.A., et al. Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study. BMJ Qual Saf 21 (2012), 810–818.
6. 6 Walshe, K., Offen, N., A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary. Qual Health Care 10 (2001), 250–256.
7. 7 Heinrich, H.W., Industrial Accident Prevention: A Scientific Approach. 1931, McGraw-Hill, New York.
8. 8 Wong, D.R., Vander Salm, T.J., Ali, I.S., Agnihotri, A.K., Bohmer, R.M., Torchiana, D.F., Prospective assessment of intraoperative precursor events during cardiac surgery. Eur J Cardiothorac Surg 29 (2006), 447–455.
9. 9 Wong, D.R., Torchiana, D.F., Vander Salm, T.J., Agnihotri, A.K., Bohmer, R.M., Ali, I.S., Impact of cardiac intraoperative precursor events on adverse outcomes. Surgery 141 (2007), 715–722.
10. 10 Martinez, E.A., Thompson, D.A., Errett, N.A., et al. High stakes and high risk: a focused qualitative review of hazards during cardiac surgery. Anesth Analg 112 (2011), 1061–1074.
11. 11 Freed, D.H., Drain, A.J., Kitcat, J., Jones, M.T., Nashef, S.A., Death in low-risk cardiac surgery: the failure to achieve a satisfactory cardiac outcome (FIASCO) study. Interact Cardiovasc Thorac Surg 9 (2009), 623–625.
12. 12 Farid, S., Page, A., Jenkins, D., Jones, M.T., Freed, D., Nashef, S.A., FIASCO II failure to achieve a satisfactory cardiac outcome study: the elimination of system errors. Interact Cardiovasc Thorac Surg 17 (2013), 116–119.
13. 13 Rasmussen, J., Skills, rules, knowledge; signals, signs, and symbols, and other distinctions in human performance models. IEEE Trans Syst Man Cybern 13 (1983), 257–266.
14. 14 Reason, J., Human Error. 1990, Cambridge University Press, Cambridge, UK.
15. 15 Perrow, C., Normal Accidents: Living With High-Risk Technologies. 1999, Princeton University Press, Princeton, NJ.
16. 16 Weick, K.E., Sutcliffe, K.M., Managing the unexpected: resilient performance in an age of uncertainty. 2nd ed., 2007, Jossey-Bass, San Francisco.
17. 17 Carthey, J., De Leval, M.R., Reason, J.T., The human factor in cardiac surgery: errors and near misses in a high technology medical domain. Ann Thorac Surg 72 (2001), 300–305.
18. 18 De Leval, M.R., Carthey, J., Wright, D.J., Farewell, V.T., Reason, J.T., Human factors and cardiac surgery: a multicenter study. J Thorac Cardiovasc Surg 119 (2000), 661–672.
19. 19 Galvan, C., Bacha, E.A., Mohr, J., Barach, P., A human factors approach to understanding patient safety during pediatric cardiac surgery. Prog Pediatr Cardiol 20 (2005), 13–20.
20. 20 Helmreich, R.L., Schaefer, H.G., Team performance in the operating room. Bogner, M.S., (eds.) Human error in medicine, 1994, Lawrence Erlbaum Assoc, Hillsdale, NJ, 225–253.
21. 21 Wiegmann, D.A., Eggman, A.A., ElBardissi, A.W., Parker, S.H., Sundt, T.M., Improving cardiac surgical care: a work systems approach. Appl Ergon 41 (2010), 701–712.
22. 22 ElBardissi, A.W., Wiegmann, D.A., Dearani, J.A., Daly, R.C., Sundt, T.M. 3rd, Application of the human factors analysis and classification system methodology to the cardiovascular surgery operating room. Ann Thorac Surg 83 (2007), 1412–1419.
23. 23 Wiegmann, D.A., ElBardissi, A.W., Dearani, J.A., Daly, R.C., Sundt, T.M. 3rd, Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery 142 (2007), 658–665.
24. 24 Woods, D.D., Dekker, S.W.A., Cook, R.I., Johannesen, L.L., Sarter, N.B., Behind human error. 2nd ed., 2010, Ashgate, Aldershot, UK.
25. 25 Hollnagel, E., Paries, J., Woods, D.D., Wreathall, J., (eds.) Resilience engineering in practice, 2011, Ashgate, Aldershot, UK.
26. 26 Sanchez, J.A., Barach, P.R., High reliability organizations and surgical microsystems: re-engineering surgical care. Surg Clin North Am 92 (2012), 1–14.
27. 27 Reason, J., Achieving a safe culture: theory and practice. Work Stress 12 (1998), 293–306.
28. 28 Wachter, R.M., Pronovost, P.J., Balancing “no blame” with accountability in patient safety. N Engl J Med 361 (2009), 1401–1406.
29. 29 Marsteller, J.A., Wen, M., Hsu, Y.J., et al. Safety culture in cardiac surgical teams: data from five programs and national surgical comparison. Ann Thorac Surg 100 (2015), 2182–2189.
30. 30 France, D.J., Leming-Lee, S., Jackson, T., Feistritzer, N.R., Higgins, M.S., An observational analysis of surgical team compliance with perioperative safety practices after crew resource management training. Am J Surg 195 (2008), 546–553.
31. 31 Stead, K., Kumar, S., Schultz, T.J., et al. Teams communicating through STEPPS. Med J Aust 190 (2009), S128–S132.
32. 32 Clancy, C.M., Tornberg, D.N., TeamSTEPPS: assuring optimal teamwork in clinical settings. Am J Med Qual 22 (2007), 214–217.
33. 33 Pisano, G.P., RMJ Bohmer, Edmondson, A.C., Organizational differences in rates of learning: evidence from the adoption of minimally invasive cardiac surgery. Manag Sci 47 (2001), 752–768.
34. 34 Edmondson, A., Psychological safety and learning behavior in work teams. Adm Sci Q 44 (1999), 350–383.
35. 35 Edmondson, A.C., Learning from failure in health care: frequent opportunities, pervasive barriers. Qual Saf Health Care 13 (2004), ii3–ii9.
36. 36 Bognár, A., Barach, P., Johnson, J.K., et al. Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac surgical teams. Ann Thorac Surg 85 (2008), 1374–1381.
37. 37 Dingley, C., Daugherty, K., Derieg, M.K., Persing, R., Improving patient safety through provider communication strategy enhancements. Henriksen, K., Battles, J.B., Keyes, M.A., et al. (eds.) Advances in patient safety: new directions and alternative approaches (Vol. 3: Performance and tools), 2008, Agency for Healthcare Research and Quality, Rockville, MD.
38. 38 Wadhera, R.K., Parker, S.H., Burkhart, H.M., et al. Is the “sterile cockpit” concept applicable to cardiovascular surgery critical intervals or critical events? The impact of protocol-driven communication during cardiopulmonary bypass. J Thorac Cardiovasc Surg 139 (2010), 312–319.
39. 39 Wahr, J.A., Prager, R.L., Abernathy, J.H., et al. Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association. Circulation 128 (2013), 1139–1169.