Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care.
Hu Y-Y, Arriaga AF, Roth EM, et al. Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care. Ann Surg. 2012;256(2):203-10. doi:10.1097/SLA.0b013e3182602564.
Analysis of video recordings of 10 complex surgical procedures identified an average of 3 deviations (delays or patient safety concerns) per procedure, most often due to problems with communication or environmental design.