Analysis of Error Management Strategies during Cardiac Surgery: Theoretical and Practical Implications

Preventing errors that threaten patient safety is a priority within all healthcare specialties. One approach is to increase the resiliency of healthcare systems by improving error management processes and by making systems more error tolerant. Research has shown that a key marker of surgical excellence is the ability of a surgical team to successfully manage errors and unexpected events during surgery. Proactively improving error management during surgery is difficult however because little is known about the cognitive mechanisms involved in error recovery or the situational factors that impact successful error management processes. This paper describes a systematic analysis of errors and error management processes during cardiovascular surgery. Results are used to develop a theoretical framework that captures the complexity of cognitive and situational factors involved in error management. The utility of this model in identifying areas within healthcare systems that can be redesigned to improve patient safety will be discussed.