Anne van Dalen

22 I General Introduction and leadership. 69 Technical errors can be defined as manual errors of the surgeon (e.g. damage to adjacent structures) or anaesthesiologist (e.g. incorrect insertion of the nasogastric tube) and procedural errors due to lack of proficiency or experience. 13,70 Technical errors are distinct from technical events; a technical event is the damage or injury that can result from a technical error. While not all technical errors lead to technical events (e.g. a foggy laparoscope camera), the identification and root cause analysis of technical errors is critical for preventing the occurrence of technical events, for mitigating the likelihood of postoperative complications and adverse outcomes, and to improve surgical performance. Operating environment Ahuman factors approach recognized that human error is often the result of a combination of both individual surgeon factors and work system factors, such as equipment used and for example communication between the team when this equipment malfunctions. 14 “Environment” is defined as “the circumstances, objects, or conditions by which one is surrounded”. In the operating room, the environment comprises the physical space, the equipment, and the people (staff and patient). Ergonomics is defined as “an applied science concerned with designing and arranging things people use, so that the people and things interact most efficiently and safely”. 17 71 Even though most surgeons have become impervious to the complexity of the operating environment, there are numerous environmental factors that could potentially affect surgical performance and therefore patient outcome. These factors could include, layout, presence and flux of personnel and ambient factors such as noise, lighting and temperature. 14,17 Operating room layout and noise have received most of the attention in the literature; however other factors could be important as well. Dankelman et al. 72 showed that not only interaction between surgeon and staff, but also surgeon-instrument and staff-technology interaction need to be addressed in causal analysis of adverse events. Thereupon, to reduce human errors, not only the human but also the system should be approached.