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Cases & Commentaries
- Web M&M
Jim Fackler, MD, and Jamie M. Schwartz, MD; October 2011
Residents and nurses assumed an ICU attending was conveying information to the surgeon and cardiologist about a toddler's deteriorating condition after heart surgery. However, none of the providers had a complete picture of the child's status, and he suffered a cardiac arrest.
Journal Article > Study
Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room.
Bowermaster R, Miller M, Ashcraft T, et al. J Am Coll Surg. 2015;220:149–155.e3.
This observational study describes how a pediatric cardiac surgery team used the human factors approach of recording even small deviations from ideal practice in order to better characterize safety problems. The authors describe how systematically capturing small failures led to recognition of faulty processes that could be addressed. A recent AHRQ WebM&M commentary discusses the application of human factors engineering to enhance safety of medical device design.