Emile Bacha, M.D.
Children’s Hospital Boston

Human Factors and Patient Safety During Congenital Heart Surgery
Amount Awarded: 2007 - $39,750

Much attention has been paid recently to medical “errors” in American hospitals. The proposed research is a quantitative and qualitative study designed to identify human factors that are a threat to the safety of infants with congenital heart disease. The purpose is to identify the occurrence and types of human factors in the operating room ( i.e. teamwork, fatigue, organizational dynamics, authority gradients, shift work and team performance ) that can potentially lead to undesirable outcomes ( i.e. adverse events, near misses and hospital death ). The incidence of such outcomes will be recorded. Also, latent conditions that lead to error, such as policies, processes, procedures and culture will be evaluated. After an initial observation period, we will apply a major safety intervention and error reduction strategy, consisting of a detailed briefing of the entire operating room staff as to incidence and types of human factors in the operating room. As well as the incidence of adverse events, near misses and hospital death, to evaluate if there was a significant post-intervention reduction. Results from this study will inform the surgical team and will lead to the redesign of training programs for operating room teams so that in addition to examining technical skills, trainees are also assessed on other skills which may influence surgical outcomes such as team coordination, communication, decision making, situation awareness and performance shaping factors.