A prospective study of patient safety in the operating room.
This study used a multidisciplinary team of human factors experts and surgeons to identify critical system features that affect patient safety. The observational team carefully followed and recorded events from 10 general surgery cases. Primary findings suggested deficiencies in communication and information flow as well as competing tasks that created poor team performance. The authors suggest this methodology may provide an effective mechanism to identify patient safety issues and potential areas for intervention.