Human factors and outcomes in pediatric cardiac surgery

Abstract

Medical accidents are estimated to be the sixth leading cause of death in the US and may cost up to $980 billion per year. To determine their causes, these accidents need to be understood in terms of the systems model of accidents and of human factors, or the study of the relationship between individuals and work systems. Healthcare systems create errors through a complex mix of factors that shape human performance, including cost and throughput demands, poor technology design, interruptions, tolerance of violations, team tensions and miscommunication, and a limited understanding and application of human factors expertise. Pediatric cardiac surgery outcomes are particularly susceptible to such problems, because children are already seriously at risk. Checklists, teamwork training, patient and parental involvement, and other improvements have all been beneficial, but all need to be considered carefully in terms of the mechanisms of their effects, their broader impact on work systems of work, their diffusion, and their sustainability. Small problems can escalate to create serious adverse outcomes, but good teamwork can help avoid these problems, avoid escalating them to more serious problems, and help recover from these problems without leading to adverse outcomes.