Anne van Dalen

4 Analyzing and discussing human factors affecting surgical patient safety I 143 Suboptimal Clinician Condition Lack of situation awareness Clinician does not appropriately perceive/comprehend current system state, unusual/unsafe circumstances, or deviation/error Suboptimal mental state Ex. Anger, frustration, arrogance, complacency Suboptimal physiological condition Ex. Hunger, fatigue Inadequate Experience/ Knowledge Insufficient task experience/knowledge Individual lacks experience to execute the task correctly/ safely/efficiently ( potential to contribute to error) Insufficient tool experience/knowledge Individual lacks experience to correctly/safely/efficiently operate or handle surgical tool ( potential to contribute to error) Leadership Failures Failure to explore concerns Clinician in leadership position does not adequately address/ explore concerns raised by co- worker Failure to guide/ supervise Absence of supervision over less experienced team members at a critical point in time Team Effectiveness Issues Personnel late Clinical team member arrives late to the OR Suboptimal team dynamics Evidence of incompatibility/ discord between team members as a result of personality differences, unfamiliar team, etc. Unnecessary conversation Clinical team members engage in trivial or unnecessary conversation that is not relevant to the task at hand