Anne van Dalen

4 Analyzing and discussing human factors affecting surgical patient safety I 119 INTRODUCTION Despite numerous improvement initiatives, such as the surgical safety checklists 1 and “safe surgery guidelines” 2 by the World Health Organization (WHO), the incidence of preventable surgical errors remains too high. 2-5 Studies have demonstrated that most surgical errors occurred not due to technical but rather to human factors related issues. 6-9 Human factors engineering studies the interaction amongst people, tools, and environments within complex systems, such as the operating room (OR). 10-12 It may help identifying common safety threats, usually defined as ‘deviations from an ideal course that can increase risk of harm to patients’. 13 In surgery, OR teams are often able to overcome safety threats, achieving good outcome. This is termed ‘resilience’, referring to the phenomenon of a complex system such as an OR team being able to successfully adapt. 14,15 A knowledge gap in literature exists on safety threats and resilience related to surgery. 5 16 17 Studies that comprehensively analyze interactions within the OR system impacting surgical quality and safety are sparse. A medical data recorder (MDR), similar to a system known in aviation as a ‘Black Box’, may be used to collect and analyze multisource data. If it is well-designed, it may facilitate the recognition of events and patterns influencing surgical safety by using validated rating scales and artificial intelligence (AI) based technology. 7 18 19 The analysis of the system may be improved by machine learning software and consequently be of value when discussing patient safety threats. 20 21 It is well-known that debriefing is the cornerstone of any learning experience. Nevertheless, a true multidisciplinary debriefing culture in surgery is still lacking. 22-24 Multidisciplinary debriefing with the use of video and data recordings, may give the team the opportunity to objectively discuss and learn from all the identified relevant factors affecting surgical patient safety. 25-27 The aim of this study was 1) to use an MDR to identify common safety threat and resilience support events in surgery and 2) to identify frequently discussed safety and quality improvement issues during structured postoperative multidisciplinary debriefings using the MDR outcome report.