Population
8 complex, high-acuity operations representing 36 hours of patient care
Design
Other
Authors
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Frequent OR deviations from team issues warrant protocol review; hypothesis-generating for system redesign trials before practice change.
Unanticipated events in the OR are common and often result from poor system design and suboptimal team dynamics, highlighting the need for system redesign and team training.
Hu et al. (2011) studied this question.
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