Background

The aim of this investigation is to place surgical disruptions in a different light. Rather than viewing these disruptions as isolated events which may affect the surgical team, we represent them as an aggregated space which serves to disconnect the team from the task at hand. Furthermore, we make the case that by understanding this error space, one can begin to target interventions that reduce the boundaries of this space and as a consequence reduce the opportunity for errors to develop.

Methods

Trained doctoral-level human factors students observed 24 cardiac procedures for flow disruptions impacting the surgical team and recorded the frequency as well as time needed to resolve these events. Observations were later coded using a human factors taxonomy and descriptive statistics were applied.

Results

A total of 693 workflow disruptions were experienced by the surgical team where interruption issues accounted for the greatest frequency of events (32.61%). Of 139.06 h of total observation time, 10.14 h was needed to resolve the 693 disruptions identified. On average, each disruption took 61.99 s to resolve.

Conclusion

While there is value in identifying the frequency of flow disruptions, this only addresses part of the problem. What is missing from analyses of this sort is the time that the healthcare professional is separated from their central task; in this case the surgeon performing thoracic surgery. This paper provides a conceptual and quantitative metric that allows for the practical application of proactive methods for identifying systemic threats.