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Search results for "Cardiothoracic Surgery"
- Cardiothoracic Surgery
- Near Miss
Cases & Commentaries
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John H. Eichhorn, MD; January 2015
While undergoing an elective coronary artery bypass graft (CABG) and ablation, an elderly man had a pulmonary artery catheter (PAC) placed to monitor his hemodynamic status. During the operation, the team was informed that another patient needed an emergency CABG. In the rush to attend to the second patient, the PAC in the first was left inflated for a prolonged period, which could have led to a catastrophic complication.
Journal Article > Review
Carthey J, de Leval MR, Reason JT. Ann Thorac Surg. 2001;72:300-305.
This review discusses the importance of human factors research in reducing adverse events. Drawing from experiences in cardiac surgery, the authors detail the process of capturing and examining various error types. They use case examples to illustrate specific incidents and demonstrate the utility of a systems approach to uncover solutions. The authors also share lessons learned from exploring similar high-complexity industries. They suggest that the profession must better refine methods for prospective analysis of surgical performance and for retrospective analysis of near misses and critical incidents.