AHRQ Patient Safety Network ► Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room.

AHRQ Patient Safety Network



Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room.

Bowermaster R, Miller M, Ashcraft T, et al. J Am Coll Surg. 2014 Nov 4; [Epub ahead of print].

This observational study describes how a pediatric cardiac surgery team used the human factors approach of recording even small deviations from ideal practice in order to better characterize safety problems. The authors describe how systematically capturing small failures led to recognition of faulty processes that could be addressed. A recent AHRQ WebM&M commentary discusses the application of human factors engineering to enhance safety of medical device design.

PubMed citation 
Available at 

Related Resources

STUDY

Preprinted order sets as a safety intervention in pediatric sedation.

Broussard M, Bass PF 3rd, Arnold CL, McLarty JW, Bocchini JA Jr. J Pediatr. 2009;154:865-868.

STUDY

Cardiac surgery errors: results from the UK National Reporting and Learning System.

Martinez EA, Shore A, Colantuoni E, et al. Int J Qual Health Care. 2011;23:151-158.

STUDY

Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital.

Vermaire D, Caruso MC, Lesko A, et al. BMJ Qual Saf. 2011;20:895-902.

STUDY

Infrequent physician use of implantable cardioverter-defibrillators risks patient safety.

Lyman S, Sedrakyan A, Do H, Razzano R, Mushlin AI. Heart. 2011;97:1655-1660.

View all related resources...