Analyzing and Discussing Human Factors Affecting Surgical Patient Safety Using Innovative Technology: Creating a Safer Operating Culture

Anne Sophie Helena Maria van Dalen, James J. Jung, Els J. M. Nieveen van Dijkum, Christianne J. Buskens, Teodor P. Grantcharov, Willem A. Bemelman, Marlies P. Schijven

Research output: Contribution to journalArticleAcademicpeer-review

1 Citation (Scopus)


Introduction Surgical errors often occur because of human factor-related issues. A medical data recorder (MDR) may be used to analyze human factors in the operating room. The aims of this study were to assess intraoperative safety threats and resilience support events by using an MDR and to identify frequently discussed safety and quality improvement issues during structured postoperative multidisciplinary debriefings using the MDR outcome report. Methods In a cross-sectional study, 35 standard laparoscopic procedures were performed and recorded using the MDR. Outcome data were analyzed using the automated Systems Engineering Initiative for Patient Safety model. The video-assisted MDR outcome report reflects on safety threat and resilience support events (categories: person, tasks, tools and technology, psychical and external environment, and organization). Surgeries were debriefed by the entire team using this report. Qualitative data analysis was used to evaluate the debriefings. Results A mean (SD) of 52.5 (15.0) relevant events were identified per surgery. Both resilience support and safety threat events were most often related to the interaction between persons (272 of 360 versus 279 of 400). During the debriefings, communication failures (also category person) were the main topic of discussion. Conclusions Patient safety threats identified by the MDR and discussed by the operating room team were most frequently related to communication, teamwork, and situational awareness. To create an even safer operating culture, educational and quality improvement initiatives should aim at training the entire operating team, as it contributes to a shared mental model of relevant safety issues.
Original languageEnglish
Pages (from-to)617-623
Number of pages7
JournalJournal of Patient Safety
Issue number6
Publication statusPublished - 1 Sept 2022


  • culture
  • human factors
  • quality improvement
  • surgical safety
  • team training
  • technology

Cite this