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PSNet: Patient Safety Network
Journal Article

System factors affecting intraoperative risk and resilience: applying a novel integrated approach to study surgical performance and patient safety.

Kolodzey L, Trbovich PL, Kashfi A, et al. Ann Surg. 2020;272(6):1164-1170.

Health systems weaknesses can hinder safe patient care. Based on recordings of complex laparoscopic general surgery procedures, this qualitative study identified both safety threats and resilience supports across multiple systems engineering categories. Safety threats associated with the physical environment (e.g., workspace design/setup), tasks, organization (e.g., unsafe staffing), and equipment (e.g., unclear instructions) were most common. Resilience supports were primarily attributed to clinician behaviors.