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J Thorac Cardiovasc Surg. 2000 Apr;119(4 Pt 1):661-72.

Human factors and cardiac surgery: a multicenter study.

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Great Ormond Street Hospital for Children NHS Trust, London, UK.



To study the role of human factors on surgical outcomes, with a series of 243 arterial switch operations performed by 21 surgeons taken as a model.


The following data were collected: patient-specific and procedural variables, self-assessment questionnaires, and a written report from a human factors researcher who observed the operation. The relationship of patient-specific variables to outcomes (death and death and/or near miss) was used to develop a multivariable baseline model to analyze the role of human factors after adjustment for these variables.


The overall mortality was 6.6% with 24.3% of cases resulting in death and death and/or near misses. The self-assessment questionnaires were found to be unhelpful. Major and minor human failures were extracted from the written report. Major negative events were potentially life-threatening failures, whereas minor events were failures that, in isolation, were not expected to have serious consequences. Major events were closely related to death (P <.001) and death and/or near misses (P <.001). Appropriate compensation, however, sharply reduced the risk of death (P =.003). The total number of minor events was also closely related to both death and death and/or near misses (P <.001).


The study highlights the role of human factors in negative surgical outcomes. Even in the most eventful circumstances, however, appropriate human factors defense mechanisms can lead to a successful outcome.

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