Anne van Dalen

4 Analyzing and discussing human factors affecting surgical patient safety I 125 Identified safety threats and resilience support events In total, 400 relevant safety threat events and 360 relevant resilience support events were observed by the MDR. A mean of 52.5 (SD 15.0) relevant events were identified per surgical case. Both resilience support events and safety threats were mostly related to the Systems Engineering Initiative for Patient Safety (SEIPS) model 7 12 category person (n = 272 and n = 279 respectively). Most resilience support events were regarded as events categorized as effective communication (n = 77). Also, high-performance behavior (n = 56) was often observed, which was subcategorized as surgical quality control. Most safety threats identified from the MDR outcome reports were regarded as events caused by unsafe acts (n = 236). In Table 2 and 3, an overview of the resilience support events and safety threats identified by MDR is presented. Team debriefing observations During the debriefings, events were also categorized as communication (person), situational awareness (person), organization or environment, according to the SEIPS model.7 12 The debriefings started with discussing a resilience support event (positive, “what went well?”) and these were most often related to effective communication (n = 26) or good situational awareness (n = 6). The second and third discussion usually concerned a safety threat, as the team was then asked “what can we do better?” and this was also most often related to communication failures (n = 10, n = 8) or lack of situational awareness (n = 10, n = 9). Due to time limitations, not all events included in the outcome report were discussed.