Devising a Framework for Measuring System Failures in Surgery
Project leads: Dr Steven Yule & Jill Wilkinson, email@example.com, Tel: 01224 273213
Funded by the Royal College of Surgeons of Edinburgh, this project investigated systems factors in the operating theatre. Systems factors are organisational, policy, equipment, task, team, individual, and patient factors that can adversely affect the smooth running of an operation and also lead to either surgical errors or decreased capacity to deal with the unexpected during operations. Data on systems factors were collected data using field notes during 42 major colorectal and orthopaedic surgical cases. These observations were analysed using the London Protocol for investigation of clinical incidents and also a card soring technique with a clinical panel. A prototype framework for prospective measurement of systems failures in surgery was then developed. A paper on this research was shortlisted by the Association of Surgeons of Great Britain and Ireland (ASGBI) for the Moynihan prize in 2010.