This study classified flow disruptions affecting the anesthesia team during cardiothoracic surgeries. Disruptions were classified into one of six human factors categories: communication, coordination, equipment issues, interruptions, layout, and usability. Interruptions accounted for nearly 40% of disruptions (e.g., events related to alerts, distractions, searching activity, spilling/dropping, teaching moment).

… at the organizational and team levels. … Gaw M, Rosinia F, Diller T. Quality and the Health System: Becoming a High …

There is a recognized challenge in developing true opportunities for improvement with incident reporting. Using a case study method, this commentary describes a tested incident assessment framework that employs charting mechanisms to monitor both harm and nonharm events that result in process or workflow changes to indicate reliability of care in real time.

Although root cause analysis is widely used to detect safety hazards, questions have been raised regarding its effectiveness. This study reports on one health system's experience using the Human Factors Analysis Classification System as an alternate method to investigate errors.