Introduction

A number of studies around the world have reported that approximately 10% of patients admitted to the hospital experience an adverse outcome – half of which are preventable with current standards of treatment. Surgical patients are particularly vulnerable to these adverse outcomes, suggesting that the operating room (OR) is a high-risk environment with considerable opportunity for error. Population-based studies have shown that 3 to 17% of surgical procedures performed in first-world countries result in adverse outcomes. These rates are suggested to be much higher in third-world countries.

In response to this high rate of error, recent initiatives have focused on understanding the factors that contribute to complications in the OR. Current methods of evaluating error involve post-operative debriefing, morbidity and mortality (M&M) conferences, and critical incident self-reporting. Recent studies have also used malpractice claims to analyze patterns of errors during a surgical procedure. These evaluative techniques are useful to an extent, but present the risk of hindsight and opinion bias due to its retrospective nature. Furthermore, these techniques primarily focus on the skills of the individual surgeon and pre-existing patient conditions, as “root” causes of error. Yet, the term “root” cause is misleading, as most adverse outcomes result from complex interactions involving the entire OR team and environmental surroundings.