Table 1 Depicting and studying “events in theatre” in order to improve human factors: the “RECORD” model

R eport

In Incident R eporting systems, error should be categorized according to the source of it; so errors can be occur due to technical failures administrative and organizational failures or human failures and violations. However regardless of its source, the correct approach to human error recognizes the need for reporting and reflecting on them. Analysis of human factors means encouraging error reporting in a non-punitive environment, where it is seen as a valuable source of information, facilitating education and future error prevention.

E valuate

Constant grading of theatre activity can be achieved by E valuation as to whether a given surgical practice is adherent to principles and protocols; for example prior to chest closure the team asks the anesthetist to make sure that the Swan-Ganz catheter is mobile and is not “caught up” with the atrial sutures; or when requesting for a IABP support the balloon size has to be double checked by perfusionists and surgeons; A patient with an air leak who comes to theatre for a VATS pleurectomy should not have the drain removed up till the chest is open for the simple risk of tension pneumothorax.

C entralize

Creation of a “C entralized cardiac registry” of major events and near misses, whereby incidences in cardiac theatres should be reported and should be used as “learning examples for avoidance”.

O bserve

O bservers: “Human factor specialists” should be experts to the procedures involved: this is an important concept because a commonly predictable event such as for example, inability to be weaned off Cardiopulmonary bypass first time due to air embolism in the coronaries could be criticized as a near miss event from an inexperienced eye.

R ecord with Video camera

Video camera R ecordings; it is been used in other specialized areas such as during performance of highly skilled actions in aviation. It is somehow difficult to appreciate as to how it could be an established monitoring tool in the operating theatre, however one has to appreciate that it provides an objective index of a performance and a reflecting tool to refer to.

D ual action: Audit and Questionnaires

Regular clinical audit forums whereby the current surgical practice is scrutinized against protocols; this is an essential component of the “smooth implementation” of surgical practices and provides room for improvement by identifying human errors and eventually correcting them by “closing the audit loop”.

The use of questionnaires: They are helpful in depicting surgical practices. A direct questioner to the surgical team could potentially refer to individual’s well- being, experience, knowledge and confidence; or it could refer to the organizational characteristics of the theatre team on action. Human factors questionnaires should be “filled in” before or during the procedure, but not afterward, to prevent hindsight bias.