Strengthening pediatric cardiac surgical safety through human factors: Anesthesia perspectives

In complex pediatric cardiac surgery, where physiological margins are narrow and multidisciplinary coordination is important, the effect of human factors, including behavioral, cognitive, and organizational, on the team performance and outcomes remains underrecognized. Even with major advances in monitoring, surgical techniques, and perfusion technology, it is often the team’s nontechnical skills, such as situational awareness, decision-making under pressure, effective communication, and workload management, which determine whether stability is maintained or a crisis develops. Pediatric cardiac anesthesia is a crucial element in the high-risk team effort, which demands precise coordination to manage unstable hemodynamics while adjusting to mental strain, stress, and fatigue from long hours. In such settings, lapses in situational awareness, such as missing a change in surgical steps, decision fatigue during prolonged cases, or communication failures from incomplete handovers or unclear instructions, can quickly erode safety margins. One pediatric anesthesia-based study found that human factors accounted for 42.5% of operating room incidents, with judgment errors (43%), failure to check (17.8%), inattention or distraction (5.6%), and communication issues (5.6%) as the most common causes.1 Similarly, a systematic review in anesthesia highlighted that human interaction and communication issues, rather than purely technical failures, are among the major contributors to adverse events.2 More recently, the Difficult Airway Society and Association of Anaesthetists published guidance reinforcing that human factors science encompassing ergonomics, systems design, and nontechnical skills training offers a structured, evidence-based approach to addressing these limitations and improving anesthesia practice.3 In pediatric cardiac surgery, the role of the anesthesiologist and the importance of human factors are even more important. The patients are small, physiology is complex, surgical plans may change unexpectedly, and hemodynamics are often labile. The multidisciplinary team, including the surgeon, perfusionist, cardiologist, intensivist, and anesthesiologist, must function smoothly, and the anesthesiologist frequently bridges communication and decision-making across interfaces. An observational study in pediatric cardiac surgery highlighted that human factors such as communication and coordination failures contributed to intraoperative adverse events, and that compensatory mechanisms were often required to prevent major complications.4 Based on these evidence and recognizing that some of these measures are already practiced in many centers, consistent and collective implementation of the following steps will help to achieve optimal outcomes in pediatric cardiac anesthesia programs. Preoperative multidisciplinary case discussions: Schedule weekly multidisciplinary cath meetings with the cardiologist, surgeon, anesthesiologist, and perfusionist to review upcoming cases, ensure everyone understands the diagnosis and complexity, anticipate individual intraoperative challenges, and agree on strategies for high-risk phases Preinduction briefing and checklists: Implement a structured briefing practice before starting the case, in which team members confirm their identities and roles using a checklist. Anesthesia, surgical, and perfusion teams share their individual concerns, such as anticipated airway challenges, proposed analgesia plan, and feasibility of on-table extubation or fast-tracking, complex anatomy and effect on surgical steps, planned cannulation technique, expected cross-clamp duration, possible need for deep hypothermic arrest, estimated blood loss, bloodless prime perfusion strategy, and cerebral monitoring requirements Intraoperative to intensive care unit (ICU) handovers: Establish a structured handover practice after transferring and stabilizing the patient in the ICU, during which the anesthesiologist, surgeon, and perfusionist jointly brief the intensivist and bedside nurse. The handover should summarize whether the surgery performed was as planned, the main intraoperative events, any unexpected complications, any residual issues after transfer, and the specific postoperative instructions. Such multidisciplinary communication ensures continuity of care and reduces information loss during these critical transitions Nontechnical skills-oriented simulation and role-play sessions: Regular simulation training and role-plays focused on intraoperative crisis management, effective communication, fatigue management, nullifying the effects of hierarchy and professional ego on clinical decisions, and resolving differences of opinion during challenging clinical situations can strengthen team performance and improve collaboration System design to reduce dependence on individual heroics: Human factors science shows that safety depends on a balanced, effective system, not just on individual skill. Clear configuration of the team, protocol, and checklist-based practice, standard equipment, minimal distractions during crucial stages, and enough staff strength will help the team work safely and consistently5 Institutional recognition and visibility for human factors initiatives: Recognizing and rewarding teamwork, communication, and safety initiatives helps keep individual members engaged and committed. Visibility through teaching roles, academic credit, and the inclusion of unit initiatives in institutional safety goals fosters shared responsibility and long-term commitment among the team. In resource-constrained settings in many pediatric cardiac units in India and other low- and middle-income countries (LMICs), the effect of human-factor burden is magnified. Staffing shortages, long working hours, limited access to simulation training, limited infrastructure, and compromised working environments demand greater cognitive ability and stronger team coordination. Recognizing human factors as a core pillar of safety rather than an optional addition is essential both clinically and ethically. In summary, improving outcomes in pediatric cardiac anesthesia requires equal attention to the child’s circulation and to how we perform as a team around that circulation. Human factors are the unspoken determinants of success; making them visible, measurable, and improvable may yield the most substantial gains in safety and outcomes. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.