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• W2343817827 abstract "At 7:34 a.m. on September 11, 1974, Eastern Air Lines Flight 212 from Charleston, SC, crashed in an open field 3.3 miles short of runway 36 at Douglas Municipal Airport in Charlotte, NC [1National Transportation Safety Board. File No. 1-0020 Aircraft Accident Report Eastern Air Lines, Inc. Charlotte, North Carolina September 11, 1974, Douglas DC-9-31, N8984e, Adopted: May 23, 1975. Report Number: NTSB-AAR-75-9. Washington, DC: National Transportation Safety Board. Available at http://www.ntsb.gov/investigations/AccidentReports/Reports/AAR7509.pdf. Accessed November 5, 2015.Google Scholar]. There was little or no wind, and the visibility was limited due to patchy dense ground fog. Of the 82 people on board, 11 survived. Notably, 5 flights preceded Flight 212 onto runway 36 without difficulty that morning. Partly based on the cockpit voice recorder, the National Transportation Safety Board determined that the likely cause of the crash was “the flight crew’s lack of altitude awareness at critical points during the approach due to poor cockpit discipline in that the crew did not follow prescribed procedures” [1National Transportation Safety Board. File No. 1-0020 Aircraft Accident Report Eastern Air Lines, Inc. Charlotte, North Carolina September 11, 1974, Douglas DC-9-31, N8984e, Adopted: May 23, 1975. Report Number: NTSB-AAR-75-9. Washington, DC: National Transportation Safety Board. Available at http://www.ntsb.gov/investigations/AccidentReports/Reports/AAR7509.pdf. Accessed November 5, 2015.Google Scholar]. Specific issues with discipline and prescribed procedures were as follows: “During the descent, until about 2 minutes and 30 seconds prior to the sound of impact, the flight crew engaged in conversations . . . (that) covered a number of subjects, from politics to used cars, and both crew members expressed strong views and mild aggravation concerning the subjects discussed. The Safety Board believes that these conversations were distractive and reflected a casual mood and lax cockpit atmosphere, which continued throughout the remainder of the approach and which contributed to the accident” [1National Transportation Safety Board. File No. 1-0020 Aircraft Accident Report Eastern Air Lines, Inc. Charlotte, North Carolina September 11, 1974, Douglas DC-9-31, N8984e, Adopted: May 23, 1975. Report Number: NTSB-AAR-75-9. Washington, DC: National Transportation Safety Board. Available at http://www.ntsb.gov/investigations/AccidentReports/Reports/AAR7509.pdf. Accessed November 5, 2015.Google Scholar]. In 1981, in response to aviation accidents, the Federal Aviation Administration imposed the “Sterile Cockpit Rule,” which states that pilots are to refrain from nonessential activities or conversations that could distract or interfere with their duties during critical phases of flight and operations below 10,000 feet [2Sumwalt RL. The sterile cockpit. ASRS Directline 1993;4:18–22. Available at http://ntl.bts.gov/data/letter_am/d14.pdfC-1. Accessed February 24, 2016.Google Scholar]. Surgical errors and adverse events include wrong or delayed operations and judgment lapses that lead to incorrect procedures [3Shanafelt T.D. Balch C.M. Bechamps G. et al.Burnout and medical errors among American surgeons.Ann Surg. 2010; 251: 995-1000Crossref PubMed Scopus (1158) Google Scholar, 4Griffen F.D. Stephens L.S. Alexander J.B. et al.The American College of Surgeons’ closed claims study: new insights for improving care.J Am Coll Surg. 2007; 204: 561-569Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 5Wahr J.A. Prager R.L. Abernathy 3rd, J.H. et al.Patient safety in the cardiac operating room: human factors and teamwork.Circulation. 2013; 128: 1139-1169Crossref PubMed Scopus (192) Google Scholar, 6Guru V. Tu J.V. Etchells E. et al.Relationship between preventability of death after coronary artery bypass graft surgery and all-cause risk-adjusted mortality rates.Circulation. 2008; 117: 2969-2976Crossref PubMed Scopus (58) Google Scholar, 7Gawande 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. 1999; 126: 66-75Abstract Full Text Full Text PDF PubMed Scopus (714) Google Scholar]. It is estimated that 54% of the adverse events in patients undergoing operations surgery are preventable [7Gawande 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. 1999; 126: 66-75Abstract Full Text Full Text PDF PubMed Scopus (714) Google Scholar]. In patients undergoing coronary artery bypass grafting, for whom the risk-adjusted mortality rate ranges from 1.3% to 3.1%, approximately one-third of associated deaths may be preventable, with most occurring in the operating room and intensive care unit [6Guru V. Tu J.V. Etchells E. et al.Relationship between preventability of death after coronary artery bypass graft surgery and all-cause risk-adjusted mortality rates.Circulation. 2008; 117: 2969-2976Crossref PubMed Scopus (58) Google Scholar]. Surgical outcomes are often attributed primarily to the technical skills of the surgeon: when errors are made, the surgeon’s competence is questioned [3Shanafelt T.D. Balch C.M. Bechamps G. et al.Burnout and medical errors among American surgeons.Ann Surg. 2010; 251: 995-1000Crossref PubMed Scopus (1158) Google Scholar, 4Griffen F.D. Stephens L.S. Alexander J.B. et al.The American College of Surgeons’ closed claims study: new insights for improving care.J Am Coll Surg. 2007; 204: 561-569Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 8Campbell Jr., D.A. Physician wellness and patient safety.Ann Surg. 2010; 251: 1001-1002Crossref PubMed Scopus (15) Google Scholar, 9Wiegmann D.A. Eggman A.A. ElBardissi A.W. Parker S.H. Sundt 3rd, T.M. Improving cardiac surgical care: a work systems approach.Appl Ergon. 2010; 41: 701-712Crossref PubMed Scopus (67) Google Scholar, 10Elbardissi A.W. Sundt T.M. Human factors and operating room safety.Surg Clin N Am. 2012; 92: 21-35Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar]. The notion that the surgeon is often held solely accountable is evidenced in the basis for surgeon rankings in public reporting. Narratives of catastrophic events in the aviation industry are commonly used to illustrate the importance of human factors in accident causation and near misses. In surgery, such an approach has emphasized that errors are the result of the characteristics of the individual surgeon combined with the dynamics imposed by the existing work system [5Wahr J.A. Prager R.L. Abernathy 3rd, J.H. et al.Patient safety in the cardiac operating room: human factors and teamwork.Circulation. 2013; 128: 1139-1169Crossref PubMed Scopus (192) Google Scholar, 6Guru V. Tu J.V. Etchells E. et al.Relationship between preventability of death after coronary artery bypass graft surgery and all-cause risk-adjusted mortality rates.Circulation. 2008; 117: 2969-2976Crossref PubMed Scopus (58) Google Scholar, 7Gawande 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. 1999; 126: 66-75Abstract Full Text Full Text PDF PubMed Scopus (714) Google Scholar, 9Wiegmann D.A. Eggman A.A. ElBardissi A.W. Parker S.H. Sundt 3rd, T.M. Improving cardiac surgical care: a work systems approach.Appl Ergon. 2010; 41: 701-712Crossref PubMed Scopus (67) Google Scholar, 10Elbardissi A.W. Sundt T.M. Human factors and operating room safety.Surg Clin N Am. 2012; 92: 21-35Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 11Carthey 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. 2001; 72: 300-305Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar, 12ElBardissi A.W. Wiegmann D.A. Dearani J.A. Sundt T.M. Application of the human factors analysis and classification system methodology to the cardiovascular surgery operating room.Ann Thorac Surg. 2007; 83: 1412-1419Abstract Full Text Full Text PDF PubMed Scopus (152) Google Scholar]. The nontechnical skills of all members involved in the care of patients, such as communication and leadership, are critical components of teamwork, and breakdowns in these components lead to disruptions and adverse events. Patient safety programs have targeted potential failure points within the system, such as those relating to the physical environment of the operating room, teamwork, tools and technology, tasks and workload, electronic medical records, and organizational processes [7Gawande 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. 1999; 126: 66-75Abstract Full Text Full Text PDF PubMed Scopus (714) Google Scholar, 9Wiegmann D.A. Eggman A.A. ElBardissi A.W. Parker S.H. Sundt 3rd, T.M. Improving cardiac surgical care: a work systems approach.Appl Ergon. 2010; 41: 701-712Crossref PubMed Scopus (67) Google Scholar, 10Elbardissi A.W. Sundt T.M. Human factors and operating room safety.Surg Clin N Am. 2012; 92: 21-35Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 11Carthey 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. 2001; 72: 300-305Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar, 12ElBardissi A.W. Wiegmann D.A. Dearani J.A. Sundt T.M. Application of the human factors analysis and classification system methodology to the cardiovascular surgery operating room.Ann Thorac Surg. 2007; 83: 1412-1419Abstract Full Text Full Text PDF PubMed Scopus (152) Google Scholar, 13Catchpole K.R. Dale T.J. Hirst D.G. Smith J.P. Giddings T.A. A multicenter trial of aviation-style training for surgical teams.J Patient Saf. 2010; 6: 180-186Crossref PubMed Scopus (81) Google Scholar, 14ElBardissi A.W. Wiegmann D.A. Henrickson S. Wadhera R. Sundt 3rd, T.M. Identifying methods to improve heart surgery: an operative approach and strategy for implementation on an organizational level.Eur J Cardiothorac Surg. 2008; 34: 1027-1033Crossref PubMed Scopus (69) Google Scholar, 15de 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. 2000; 119: 661-672Abstract Full Text Full Text PDF PubMed Scopus (403) Google Scholar, 16Catchpole K.R. Giddings A.E. Wilkinson M. Hirst G. Dale T. de Leval M.R. Improving patient safety by identifying latent failures in successful operations.Surgery. 2007; 142: 102-110Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar]. Despite the publication of the Institute of Medicine report “To err is human” in 1999 and the World Health Organization (WHO) guidelines in 2008 identifying multiple practices to improve surgical safety, the pace of safety improvement has remained relatively slow [17Kohn L. Corrigan J. Donaldson M. To err is human: building a safer health system (Institute of Medicine Report). National Academy Press, Washington, DC1999Google Scholar, 18World Alliance for Patient SafetyWHO surgical safety checklist and implementation manual. World Health Organization, Geneva, Switzerland2008http://www.who.int/patientsafety/safesurgery/ss_checklist/en/Google Scholar, 19Wachter R.M. Patient safety at ten: unmistakable progress, troubling gaps.Health Aff (Millwood). 2010; 29: 165-173Crossref PubMed Scopus (303) Google Scholar]. Notwithstanding the Sterile Cockpit directive, mistakes continue to occur during takeoff and landing of aircraft [20Federal Aviation Administration. Press release – FAA calls on airlines to limit cockpit distractions. Available at http://www.faa.gov/news/press_releases/news_story.cfm?newsId=11338. Accessed November 5, 2015.Google Scholar, 21Federal Aviation Administration. Information for operators (InFO) 10003. Cockpit distractors. Available at http://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/info/all_infos/media/2010/InFO10003.pdf. Accessed November 5, 2015.Google Scholar]. To illustrate, in October 2009, 28 years after the Sterile Cockpit Rule, the pilots of Northwest Flight 188 overflew their destination by 150 miles because they were using their laptop computers for personal activities [20Federal Aviation Administration. Press release – FAA calls on airlines to limit cockpit distractions. Available at http://www.faa.gov/news/press_releases/news_story.cfm?newsId=11338. Accessed November 5, 2015.Google Scholar, 21Federal Aviation Administration. Information for operators (InFO) 10003. Cockpit distractors. Available at http://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/info/all_infos/media/2010/InFO10003.pdf. Accessed November 5, 2015.Google Scholar]. In another instance, a pilot was texting after the aircraft pushed back from the gate and before the takeoff sequence. As a consequence of these and other lapses, the Federal Aviation Administration issued an advisory in 2010 to crew members that cockpit distraction, including the use of personal electronic devices (PEDs) for unrelated activities, “constitutes a safety risk” and that the operators and directors of operations needed “to create a safety culture that clearly establishes guidance, expectations and requirements to control cockpit distractions, including use of PEDs, during flight operations” [20Federal Aviation Administration. Press release – FAA calls on airlines to limit cockpit distractions. Available at http://www.faa.gov/news/press_releases/news_story.cfm?newsId=11338. Accessed November 5, 2015.Google Scholar, 21Federal Aviation Administration. Information for operators (InFO) 10003. Cockpit distractors. Available at http://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/info/all_infos/media/2010/InFO10003.pdf. Accessed November 5, 2015.Google Scholar]. The question is why, even in the high-risk aviation industry and in view of the Sterile Cockpit Rule, do judgment errors (eg, use of distractive devices) continue to occur? Similarly, in the health care environment, it has been posited that many explanatory factors for errors “remain to be uncovered” [3Shanafelt T.D. Balch C.M. Bechamps G. et al.Burnout and medical errors among American surgeons.Ann Surg. 2010; 251: 995-1000Crossref PubMed Scopus (1158) Google Scholar, 22Kazandjian V.A. Does appropriate prescribing result in safer care?.Qual Saf Health Care. 2004; 13: 9-10Crossref PubMed Scopus (4) Google Scholar]. Although analyzing work systems represents an important approach to human factors, one must not forget that human factors are inextricably linked to human nature, the study of which in other domains may provide insights into future interventions. This review is thus focused on individual-centered factors that affect patient outcomes. Along with factors in work systems identified above, we propose that surgeon-centered factors are based on at least three strategies: minimizing external distractions, improving interpersonal communication and teamwork, and mitigating work-related stress [3Shanafelt T.D. Balch C.M. Bechamps G. et al.Burnout and medical errors among American surgeons.Ann Surg. 2010; 251: 995-1000Crossref PubMed Scopus (1158) Google Scholar, 5Wahr J.A. Prager R.L. Abernathy 3rd, J.H. et al.Patient safety in the cardiac operating room: human factors and teamwork.Circulation. 2013; 128: 1139-1169Crossref PubMed Scopus (192) Google Scholar, 9Wiegmann D.A. Eggman A.A. ElBardissi A.W. Parker S.H. Sundt 3rd, T.M. Improving cardiac surgical care: a work systems approach.Appl Ergon. 2010; 41: 701-712Crossref PubMed Scopus (67) Google Scholar, 10Elbardissi A.W. Sundt T.M. Human factors and operating room safety.Surg Clin N Am. 2012; 92: 21-35Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar]. Few would argue that minimizing distractions in the operating room is ideal. However, until there is a complete understanding of its importance by all intraoperative personnel, it will remain an elusive goal. To date, one focus has been to minimize clutter and congestion in the operating room to improve surgical work flow [9Wiegmann D.A. Eggman A.A. ElBardissi A.W. Parker S.H. Sundt 3rd, T.M. Improving cardiac surgical care: a work systems approach.Appl Ergon. 2010; 41: 701-712Crossref PubMed Scopus (67) Google Scholar, 10Elbardissi A.W. Sundt T.M. Human factors and operating room safety.Surg Clin N Am. 2012; 92: 21-35Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 23Brogmus G. Leone W. Butler L. et al.Best practices in OR suite layout and equipment choices to reduce slips, trips, and falls.AORN J. 2007; 86: 384-394Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar]. With increased awareness, many surgical teams have successfully established a highly functional physical environment. Nonetheless, work flow and communication in the operating room may be improved such as by optimizing the setup and location of the cardiopulmonary bypass circuit [24Wiegmann D. Suther T. Neal J. Parker S.H. Sundt T.M. A human factors analysis of cardiopulmonary bypass machines.J Extra Corpor Technol. 2009; 41: 57-63PubMed Google Scholar]. Another important source of distraction in the operating room is the problem of noise—specifically, sudden, unexpected noise—which may increase the level of stress among the providers and impede the flow of the operation [9Wiegmann D.A. Eggman A.A. ElBardissi A.W. Parker S.H. Sundt 3rd, T.M. Improving cardiac surgical care: a work systems approach.Appl Ergon. 2010; 41: 701-712Crossref PubMed Scopus (67) Google Scholar, 10Elbardissi A.W. Sundt T.M. Human factors and operating room safety.Surg Clin N Am. 2012; 92: 21-35Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 25Carthey J. Woodward S. Adams S. et al.Patient safety. Safe and sound.Health Serv J. 2003; 113: 2-6PubMed Google Scholar, 26Hodge B. Thompson J.F. Noise pollution in the operating theatre.Lancet. 1990; 335: 891-894Abstract PubMed Scopus (168) Google Scholar, 27Kurmann A. Peter M. Tschan F. Muhlemann K. Candinas D. Beldi G. Adverse effect of noise in the operating theatre on surgical-site infection.Br J Surg. 2011; 98: 1021-1025Crossref PubMed Scopus (78) Google Scholar]. To decrease noise and distraction in the operating room, some have suggested limiting the number of visitors, optimizing the alarms systems, restricting the use of pagers, and discouraging conversations unrelated to the procedure [5Wahr J.A. Prager R.L. Abernathy 3rd, J.H. et al.Patient safety in the cardiac operating room: human factors and teamwork.Circulation. 2013; 128: 1139-1169Crossref PubMed Scopus (192) Google Scholar, 9Wiegmann D.A. Eggman A.A. ElBardissi A.W. Parker S.H. Sundt 3rd, T.M. Improving cardiac surgical care: a work systems approach.Appl Ergon. 2010; 41: 701-712Crossref PubMed Scopus (67) Google Scholar, 10Elbardissi A.W. Sundt T.M. Human factors and operating room safety.Surg Clin N Am. 2012; 92: 21-35Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar]. Although conceptually straightforward, the practicality of implementing these proposals may not be. For instance, turning off the telephone ring tone or the intravenous pump alarm is not always possible based on the perceived needs of the operating room staff and the anesthesiology team. Eliminating distractions during critical periods of an operation (akin to the Sterile Cockpit Rule) is challenging given that these periods are dynamic and may not be apparent to those not closely monitoring the procedure [28Wadhera 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. 2010; 139: 312-319Abstract Full Text Full Text PDF PubMed Scopus (109) Google Scholar]. Limiting the number of observers, though well intentioned, may lead to the perception that the surgeon is ill tempered and not interested in medical education. Finally, because prospective data on the direct effect of sudden noise on patient outcomes are lacking, the staff may not fully appreciate the beneficial effect of noise reduction in the operating room. From the perspective of social psychology, intermittent and unpredictable noise increases a person’s feeling of stress and decreases his ability to concentrate and perform complex tasks [29Haidt J.H. The happiness hypothesis: finding modern truth in ancient wisdom. Basic Books, New York2006Google Scholar, 30Glass D.C. Singer J.E. Behavioral aftereffects of unpredictable and uncontrollable aversive events.Am Sci. 1972; 60: 457-465PubMed Google Scholar]. Although there is evidence that some adaptation to noise occurs over time, individuals in noisy environments never fully adapt and continue to evidence impaired cognitive function. Study subjects who can anticipate and have some degree of control over the noise are less distressed by it [29Haidt J.H. The happiness hypothesis: finding modern truth in ancient wisdom. Basic Books, New York2006Google Scholar, 30Glass D.C. Singer J.E. Behavioral aftereffects of unpredictable and uncontrollable aversive events.Am Sci. 1972; 60: 457-465PubMed Google Scholar]. The need to reduce the negative effect of noise and the limited ability of the surgical team to adapt must be acknowledged and respected. The surgeon, anesthesiologist, and other operating room personnel should be encouraged to develop specific tactics to mitigate the frequency and effect of noise and other distractions. Studies of human factors have emphasized the importance of teamwork and communication, the effectiveness of which is often evident among familiar team members [5Wahr J.A. Prager R.L. Abernathy 3rd, J.H. et al.Patient safety in the cardiac operating room: human factors and teamwork.Circulation. 2013; 128: 1139-1169Crossref PubMed Scopus (192) Google Scholar, 9Wiegmann D.A. Eggman A.A. ElBardissi A.W. Parker S.H. Sundt 3rd, T.M. Improving cardiac surgical care: a work systems approach.Appl Ergon. 2010; 41: 701-712Crossref PubMed Scopus (67) Google Scholar, 10Elbardissi A.W. Sundt T.M. Human factors and operating room safety.Surg Clin N Am. 2012; 92: 21-35Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 14ElBardissi A.W. Wiegmann D.A. Henrickson S. Wadhera R. Sundt 3rd, T.M. Identifying methods to improve heart surgery: an operative approach and strategy for implementation on an organizational level.Eur J Cardiothorac Surg. 2008; 34: 1027-1033Crossref PubMed Scopus (69) Google Scholar]. “Primary” surgical teams, defined as those in which most team members are routinely matched together, have a lower number of surgical flow disruptions and errors compared with “secondary” surgical teams, where members have little familiarity with each other [14ElBardissi A.W. Wiegmann D.A. Henrickson S. Wadhera R. Sundt 3rd, T.M. Identifying methods to improve heart surgery: an operative approach and strategy for implementation on an organizational level.Eur J Cardiothorac Surg. 2008; 34: 1027-1033Crossref PubMed Scopus (69) Google Scholar]. Because team stability improves awareness of the progression of the case, temporary or permanent staff changes may compromise the shared knowledge of intraoperative events. Despite issues with resource allocation, many centers have made efforts to minimize staff changes during cardiothoracic surgical procedures and to have specific personnel assigned to a team to maintain optimal teamwork. However, expecting primary surgical team members to operate as a unit without some personnel changes among nursing and anesthesiology staff is not always possible or sustainable because of workload concerns and organizational culture. When personnel changes do occur during the course of an operation, they should involve structured, robust “hand-off” practices to preserve the continuity and flow of the procedure. The Joint Commission report between 2014 and 2015 indicated that failure in communication and human factors were the two leading root causes of sentinel events that resulted in operative and postoperative complications [31The Joint Commission. Sentinel event data: root causes by event type. 2004–3Q 2015. Available at http://www.jointcommission.org/Sentinel_Event_Statistics/. Accessed February 5, 2016.Google Scholar]. Teamwork failures in cardiac operations are commonly attributed to communication issues, leading to a lack of role clarity among team members, resource waste, tension, procedural violations, and errors [5Wahr J.A. Prager R.L. Abernathy 3rd, J.H. et al.Patient safety in the cardiac operating room: human factors and teamwork.Circulation. 2013; 128: 1139-1169Crossref PubMed Scopus (192) Google Scholar, 14ElBardissi A.W. Wiegmann D.A. Henrickson S. Wadhera R. Sundt 3rd, T.M. Identifying methods to improve heart surgery: an operative approach and strategy for implementation on an organizational level.Eur J Cardiothorac Surg. 2008; 34: 1027-1033Crossref PubMed Scopus (69) Google Scholar, 31The Joint Commission. Sentinel event data: root causes by event type. 2004–3Q 2015. Available at http://www.jointcommission.org/Sentinel_Event_Statistics/. Accessed February 5, 2016.Google Scholar]. To date, many team effectiveness models have been developed to enhance team performance and communication, but there is no consensus about which approach is optimal [5Wahr J.A. Prager R.L. Abernathy 3rd, J.H. et al.Patient safety in the cardiac operating room: human factors and teamwork.Circulation. 2013; 128: 1139-1169Crossref PubMed Scopus (192) Google Scholar, 13Catchpole K.R. Dale T.J. Hirst D.G. Smith J.P. Giddings T.A. A multicenter trial of aviation-style training for surgical teams.J Patient Saf. 2010; 6: 180-186Crossref PubMed Scopus (81) Google Scholar, 32Armour Forse R. Bramble J.D. McQuillan R. Team training can improve operating room performance.Surgery. 2011; 150: 771-778Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 33Nurok M. Lipsitz S. Satwicz P. Kelly A. Frankel A. A novel method for reproducibly measuring the effects of interventions to improve emotional climate, indices of team skills and communication, and threat to patient outcome in a high-volume thoracic surgery center.Arch Surg. 2010; 145: 489-495Crossref PubMed Scopus (16) Google Scholar]. One proposal to improve communication and to reduce the possibility of error is to use standardized time-outs, checklists, and preoperative briefings [18World Alliance for Patient SafetyWHO surgical safety checklist and implementation manual. World Health Organization, Geneva, Switzerland2008http://www.who.int/patientsafety/safesurgery/ss_checklist/en/Google Scholar, 34Haynes A.B. Weiser T.G. Berry W.R. et al.Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population.N Engl J Med. 2009; 360: 491-499Crossref PubMed Scopus (3788) Google Scholar, 35van Klei W.A. Hoff R.G. van Aarnhem E.E. et al.Effects of the introduction of the WHO “Surgical Safety Checklist” on in-hospital mortality: a cohort study.Ann Surg. 2012; 255: 44-49Crossref PubMed Scopus (309) Google Scholar, 36Haynes A.B. Berry W.R. Gawande A.A. What do we know about the safe surgery checklist now?.Ann Surg. 2015; 261: 829-830Crossref PubMed Scopus (24) Google Scholar, 37Bosk C.L. Dixon-Woods M. Goeschel C.A. Pronovost P.J. Reality check for checklists.Lancet. 2009; 374: 444-445Abstract Full Text Full Text PDF PubMed Scopus (329) Google Scholar]. Unlike briefings, which are discussions guided by a structured but open-ended format, checklists and time-outs (mandated by the Joint Commission) typically are close-ended, with specific information called out and verified [5Wahr J.A. Prager R.L. Abernathy 3rd, J.H. et al.Patient safety in the cardiac operating room: human factors and teamwork.Circulation. 2013; 128: 1139-1169Crossref PubMed Scopus (192) Google Scholar, 38Ziewacz J.E. Arriaga A.F. Bader A.M. et al.Crisis checklists for the operating room: development and pilot testing.J Am Coll Surg. 2011; 213: 212-217Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar]. Implementation of the WHO “Surgical Safety Checklist” has been associated with reduced rates of death from 1.5% to 0.8% and complications from 11% to 7% among patients undergoing noncardiac operations [34Haynes A.B. Weiser T.G. Berry W.R. et al.Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population.N Engl J Med. 2009; 360: 491-499Crossref PubMed Scopus (3788) Google Scholar]. The WHO checklist includes standardized time-outs, specifically before induction of anesthesia, before skin incision, and before the patient leaves the operating room [18World Alliance for Patient SafetyWHO surgical safety checklist and implementation manual. World Health Organization, Geneva, Switzerland2008http://www.who.int/patientsafety/safesurgery/ss_checklist/en/Google Scholar]. Checklists also can be useful in guiding crisis management scenarios such as failed intubation, pulseless electrical activity, air embolus, and malignant hyperthermia [5Wahr J.A. Prager R.L. Abernathy 3rd, J.H. et al.Patient safety in the cardiac operating room: human factors and teamwork.Circulation. 2013; 128: 1139-1169Crossref PubMed Scopus (192) Google Scholar, 38Ziewacz J.E. Arriaga A.F. Bader A.M. et al.Crisis checklists for the operating room: development and pilot testing.J Am Coll Surg. 2011; 213: 212-217Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar]. In cardiac surgery, development and implementation of a hemostasis checklist based on the most common sites of bleeding a" @default.
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• W2343817827 title "Human Factors and Human Nature in Cardiothoracic Surgery" @default.
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