Human Factors and Outcomes in Pediatric Cardiac Surgery



Medical accidents are estimated to be the sixth leading cause of death in the US and may cost up to $980 billion per year. To determine their causes, these accidents need to be understood in terms of the systems model of accidents and of human factors, or the study of the relationship between individuals and work systems. Healthcare systems create errors through a complex mix of factors that shape human performance, including cost and throughput demands, poor technology design, interruptions, tolerance of violations, team tensions and miscommunication, and a limited understanding and application of human factors expertise.

Pediatric cardiac surgery outcomes are particularly susceptible to such problems, because children are already seriously at risk. Checklists, teamwork training, patient and parental involvement, and other improvements have all been beneficial, but all need to be considered carefully in terms of the mechanisms of their effects, their broader impact on work systems of work, their diffusion, and their sustainability. Small problems can escalate to create serious adverse outcomes, but good teamwork can help avoid these problems, avoid escalating them to more serious problems, and help recover from these problems without leading to adverse outcomes.


Human Factors Error Safety Performance Systems Accidents Checklists Teamwork 


  1. 1.
    Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324(6):377–84.PubMedGoogle Scholar
  2. 2.
    Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery. 1999;126(1):66–75.PubMedGoogle Scholar
  3. 3.
    Thomas EJ, Studdert DM, Runciman WB, et al. A comparison of iatrogenic injury studies in Australia and the USA. I: context, methods, casemix, population, patient and hospital characteristics. Int J Qual Health Care. 2000;12(5):371–8.PubMedGoogle Scholar
  4. 4.
    Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. Br Med J. 2001;322:517–9.Google Scholar
  5. 5.
    Department of Health. An organisation with a memory: report of an expert group on learning from adverse events in the NHS. London: HMSO; 2000.Google Scholar
  6. 6.
    McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635–45.PubMedGoogle Scholar
  7. 7.
    Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000.Google Scholar
  8. 8.
    Classen DC, Resar R, Griffin F, et al. ‘Global trigger tool’ shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood). 2011;30(4):581–9.Google Scholar
  9. 9.
    Kreckler S, Catchpole KR, New SJ, Handa A, McCulloch PG. Quality and safety on an acute surgical ward an exploratory cohort study of process and outcome. Ann Surg. 2009;250(6):1035–40.PubMedGoogle Scholar
  10. 10.
    Andel C, Davidow SL, Hollander M, Moreno DA. The economics of health care quality and medical errors. J Health Care Finance. 2012;39(1):39–50.PubMedGoogle Scholar
  11. 11.
    Neale G, Woloshynowych M, Vincent C. Exploring the causes of adverse events in NHS hospital practice. J R Soc Med. 2001;94(7):322–30.PubMedCentralPubMedGoogle Scholar
  12. 12.
    Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. 2003;133(6):614–21.PubMedGoogle Scholar
  13. 13.
    Davidson TM. Anatomy of a medical accident. West J Med. 2000;172(4):267–70.PubMedCentralPubMedGoogle Scholar
  14. 14.
    Hofer TP, Hayward RA. Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. Ann Intern Med. 2002;137(5):327–33.PubMedGoogle Scholar
  15. 15.
    Woolf SH, Kuzel AJ, Dovey SM, Phillips RL. A string of mistakes: the importance of cascade analysis in describing, counting, and preventing medical errors. Ann Fam Med. 2004;2:317–26.PubMedCentralPubMedGoogle Scholar
  16. 16.
    Reason J. Human error: models and management. Br Med J. 2000;320(7237):768–70.Google Scholar
  17. 17.
    Reason JT. Human error. Cambridge: University Press; 1990.Google Scholar
  18. 18.
    Reason J. Managing the risks of organisational accidents. Aldershot: Ashgate; 1997.Google Scholar
  19. 19.
    Gurses AP, Ozok AA, Pronovost PJ. Time to accelerate integration of human factors and ergonomics in patient safety. BMJ Qual Saf. 2012;21(4):347–51.PubMedGoogle Scholar
  20. 20.
    Russ AL, Fairbanks RJ, Karsh BT, Militello LG, Saleem JJ, Wears RL. The science of human factors: separating fact from fiction. BMJ Qual Saf. 2013;22(10):802–8.PubMedCentralPubMedGoogle Scholar
  21. 21.
    Lawton R, Ward NJ. A systems analysis of the Ladbroke Grove rail crash. Accid Anal Prev. 2005;37(2):235–44.PubMedGoogle Scholar
  22. 22.
    Helmreich RL, Foushee HC. Why crew resource management? Empirical and theoretical bases of human factors training in aviation. In: Cockpit resource management. San Diego: Academic; 1993. p. 3–45.Google Scholar
  23. 23.
    Helmreich RL. Anatomy of a system accident: the crash of Avianca Flight 052. Int J Aviat Psychol. 1994;4(3):265–84.PubMedGoogle Scholar
  24. 24.
    Helmreich RL, Merritt AC. Culture at work in aviation and medicine. Aldershot: Ashgate; 1998.Google Scholar
  25. 25.
    Hetherington C, Flin R, Mearns K. Safety in shipping: the human element. J Safety Res. 2006;37(4):401–11.PubMedGoogle Scholar
  26. 26.
    Carvalho PV, Dos S, Vidal MC. Safety implications of cultural and cognitive issues in nuclear power plant operation. Appl Ergon. 2006;37(2):211–23.PubMedGoogle Scholar
  27. 27.
    Burke CS, Salas E, Wilson-Donnelly K, Priest H. How to turn a team of experts into an expert medical team: guidance from the aviation and military communities. Qual Saf Health Care. 2004;13 Suppl 1(1475–3898 (Print)):i96–104.Google Scholar
  28. 28.
    Klein G. Naturalistic decision making. Hum Factors. 2008;50(3):456–60.PubMedGoogle Scholar
  29. 29.
    Wahr JA, Prager RL, Abernathy JH, et al. Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association. Circulation. 2013;128(10):1139–69.PubMedGoogle Scholar
  30. 30.
    Cook R. “Going solid”: a model of system dynamics and consequences for patient safety. Qual Saf Health Care. 2005;14(2):130–4.PubMedCentralPubMedGoogle Scholar
  31. 31.
    Stanhope N, Crowley-Murphy M, Vincent C, O’Connor AM, Taylor-Adams SE. An evaluation of adverse incident reporting. J Eval Clin Pract. 1999;5(1):5–12.PubMedGoogle Scholar
  32. 32.
    Evans SM, Berry JG, Smith BJ, et al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care. 2006;15(1):39–43.PubMedCentralPubMedGoogle Scholar
  33. 33.
    Kreckler S, Catchpole K, McCulloch P, Handa A. Factors influencing incident reporting in surgical care. Qual Saf Health Care. 2009;18(2):116–20.PubMedGoogle Scholar
  34. 34.
    Dekker SW. The field guide to human error investigations, vol. 1. Aldershot: Ashgate; 2002.Google Scholar
  35. 35.
    Dekker SW. Accidents are normal and human error does not exist: a new look at the creation of occupational safety. Int J Occup Saf Ergon. 2003;9(2):211–8.PubMedGoogle Scholar
  36. 36.
    Wood G. The I-knew-it-all-along effect. J Exp Psychol Hum Percept Perform. 1978;4:345–53.Google Scholar
  37. 37.
    Berlin L. Hindsight bias. Am J Roentgenol. 2000;175(3):597–601.Google Scholar
  38. 38.
    Sujan MA, Harrison MD, Steven A, Pearson PH, Vernon SJ. Demonstration of safety in healthcare organisations. In: Gorski J, editor. Computer safety, reliability, and security, proceedings, vol 4166. 2006. p. 219–32.Google Scholar
  39. 39.
    Sujan MA, Koornneef F, Chozos N, Pozzi S, Kelly T. Safety cases for medical devices and health information technology: involving health-care organisations in the assurance of safety. Health Informatics J. 2013;19(3):165–82.PubMedGoogle Scholar
  40. 40.
    Gordon M, Catchpole K, Baker P. Human factors perspective on the prescribing behavior of recent medical graduates: implications for educators. Adv Med Educ Pract. 2013;4:1–9.PubMedCentralPubMedGoogle Scholar
  41. 41.
    Gagliardi AR, Brouwers MC, Palda VA, Lemieux-Charles L, Grimshaw JM. How can we improve guideline use? A conceptual framework of implementability. Implement Sci. 2011;6:26.PubMedCentralPubMedGoogle Scholar
  42. 42.
    Dixon-Woods M, McNicol S, Martin G. Ten challenges in improving quality in healthcare: lessons from the Health Foundation’s programme evaluations and relevant literature. BMJ Qual Saf. 2012;21(10):876–84.PubMedCentralPubMedGoogle Scholar
  43. 43.
    de Saint MG, Auroy Y, Vincent C, Amalberti R. The natural lifespan of a safety policy: violations and system migration in anaesthesia. Qual Saf Health Care. 2010;19(4):327–31.Google Scholar
  44. 44.
    Catchpole K. Toward the modelling of safety violations in healthcare systems. BMJ Qual Saf. 2013;22(9):705–9.PubMedGoogle Scholar
  45. 45.
    Gurses AP, Kim G, Martinez EA, et al. Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study. BMJ Qual Saf. 2012;21(10):810–8.PubMedGoogle Scholar
  46. 46.
    Staggers N, Clark L, Blaz JW, Kapsandoy S. Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses’ handoffs on medical and surgical units: insights from interviews and observations. Health Informatics J. 2011;17(3):209–23.PubMedGoogle Scholar
  47. 47.
    Catchpole K, Godden PJ, Giddings AEB, et al. Identifying and reducing errors in the operating theatre. Patient Safety Research Programme. 2005:PS012. Available at:
  48. 48.
    Catchpole KR, Giddings AE, de Leval MR, et al. Identification of systems failures in successful paediatric cardiac surgery. Ergonomics. 2006;49(5–6):567–88.PubMedGoogle Scholar
  49. 49.
    Catchpole K, Mishra A, Handa A, McCulloch P. Teamwork and error in the operating room: analysis of skills and roles. Ann Surg. 2008;247(4):699–706.PubMedGoogle Scholar
  50. 50.
    Thammasitboon S, Singhal G. System-related factors contributing to diagnostic errors. Curr Probl Pediatr Adolesc Health Care. 2013;43(9):242–7.PubMedGoogle Scholar
  51. 51.
    Catchpole KR, Giddings AE, Wilkinson M, Hirst G, Dale T, de Leval MR. Improving patient safety by identifying latent failures in successful operations. Surgery. 2007;142(1):102–10.PubMedGoogle Scholar
  52. 52.
    Alvarez G, Coiera E. Interruptive communication patterns in the intensive care unit ward round. Int J Med Inform. 2005;74(10):791–6.PubMedGoogle Scholar
  53. 53.
    Brixey JJ, Tang ZH, Robinson DJ, et al. Interruptions in a level one trauma center: a case study. Int J Med Inform. 2008;77(4):235–41.PubMedCentralPubMedGoogle Scholar
  54. 54.
    Kreckler S, Catchpole K, Bottomley M, Handa A, McCulloch P. Interruptions during drug rounds: an observational study. Br J Nurs. 2008;17(21):1326–30.PubMedGoogle Scholar
  55. 55.
    Grundgeiger T, Sanderson P. Interruptions in healthcare: theoretical views. Int J Med Inform. 2009;78(5):293–307.PubMedGoogle Scholar
  56. 56.
    Alper SJ, Holden RJ, Scanlon MC, et al. Self-reported violations during medication administration in two paediatric hospitals. BMJ Qual Saf. 2012;21(5):408–15.PubMedCentralPubMedGoogle Scholar
  57. 57.
    Amalberti R, Vincent C, Auroy Y, de Saint MG. Violations and migrations in health care: a framework for understanding and management. Qual Saf Health Care. 2006;15 Suppl 1:i66–71.PubMedCentralPubMedGoogle Scholar
  58. 58.
    Flin R, Patey R. Improving patient safety through training in non-technical skills. BMJ. 2009;339(1468–5833 (Electronic)):b3595.Google Scholar
  59. 59.
    Undre S, Sevdalis N, Healey AN, Darzi SA, Vincent CA. Teamwork in the operating theatre: cohesion or confusion? J Eval Clin Pract. 2006;12(2):182–9.PubMedGoogle Scholar
  60. 60.
    Mishra A, Catchpole K, Dale T, McCulloch P. The influence of non-technical performance on technical outcome in laparoscopic cholecystectomy. Surg Endosc. 2008;22(1):68–73.PubMedGoogle Scholar
  61. 61.
    McFerran S, Nunes J, Pucci D, Zuniga A. Perinatal patient safety project: a multicenter approach to improve performance reliability at Kaiser Permanente. J Perinat Neonatal Nurs. 2005;19(1):37–45.PubMedGoogle Scholar
  62. 62.
    Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13 Suppl 1(1475–3898 (Print)):i85–i90.Google Scholar
  63. 63.
    Sexton JB, Thomas EJ, Helmreich RL. Error, stress and teamwork in medicine and aviation: cross sectional surveys. Br Med J. 2000;320:745–9.Google Scholar
  64. 64.
    Catchpole K. Who do we blame when it all goes wrong? Qual Saf Health Care. 2009;18(1):3–4.PubMedGoogle Scholar
  65. 65.
    Hignett S, Carayon P, Buckle P, Catchpole K. State of science: human factors and ergonomics in healthcare. Ergonomics. 2013;56(10):1491–503.PubMedGoogle Scholar
  66. 66.
    Catchpole K. Spreading human factors expertise in healthcare: untangling the knots in people and systems. BMJ Qual Saf. 2013;22(10):793–7.PubMedGoogle Scholar
  67. 67.
    Leape LL, Berwick DM. Five years after to err is human: what have we learned? JAMA. 2005;293(19):2384–90.PubMedGoogle Scholar
  68. 68.
    Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg. 2008;143(1):12–7.PubMedGoogle Scholar
  69. 69.
    Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–9.PubMedGoogle Scholar
  70. 70.
    Verdaasdonk EG, Stassen LP, Widhiasmara PP, Dankelman J. Requirements for the design and implementation of checklists for surgical processes. Surg Endosc. 2009;23(4):715–26.PubMedGoogle Scholar
  71. 71.
    Makary MA, Mukherjee A, Sexton JB, et al. Operating room briefings and wrong-site surgery. J Am Coll Surg. 2007;204(2):236–43.PubMedGoogle Scholar
  72. 72.
    Berenholtz SM, Schumacher K, Hayanga AJ, et al. Implementing standardized operating room briefings and debriefings at a large regional medical center. Jt Comm J Qual Patient Saf. 2009;35(8):391–7.PubMedGoogle Scholar
  73. 73.
    de Vries EN, Hollmann MW, Smorenburg SM, Gouma DJ, Boermeester MA. Development and validation of the SURgical PAtient Safety System (SURPASS) checklist. Qual Saf Health Care. 2009;18(2):121–6.PubMedGoogle Scholar
  74. 74.
    Arora V, Johnson J. A model for building a standardized hand-off protocol. Jt Comm J Qual Patient Saf. 2006;32(11):646–55.PubMedGoogle Scholar
  75. 75.
    Dobson I, Doan Q, Hung G. A systematic review of patient tracking systems for use in the pediatric emergency department. J Emerg Med. 2013;44:242–8.PubMedGoogle Scholar
  76. 76.
    Dickson EW, Singh S, Cheung DS, Wyatt CC, Nugent AS. Application of lean manufacturing techniques in the Emergency Department. J Emerg Med. 2009;37(2):177–82.PubMedGoogle Scholar
  77. 77.
    McCulloch P, Kreckler S, New S, Sheena Y, Handa A, Catchpole K. Effect of a “Lean” intervention to improve safety processes and outcomes on a surgical emergency unit. BMJ. 2010;341(0959-535X (Linking)):c5469.Google Scholar
  78. 78.
    Berguer R. Surgery and ergonomics. Arch Surg. 1999;134(9):1011–6.PubMedGoogle Scholar
  79. 79.
    McDonald KM, Bryce CL, Graber ML. The patient is in: patient involvement strategies for diagnostic error mitigation. BMJ Qual Saf. 2013;22 Suppl 2:ii33–9.PubMedGoogle Scholar
  80. 80.
    Nathan AT, Hoehn KS, Ittenbach RF, et al. Assessment of parental decision-making in neonatal cardiac research: a pilot study. J Med Ethics. 2010;36(2):106–10.PubMedGoogle Scholar
  81. 81.
    Torowicz D, Lisanti AJ, Rim JS, Medoff-Cooper B. A developmental care framework for a cardiac intensive care unit: a paradigm shift. Adv Neonatal Care. 2012;12 Suppl 5:S28–32.PubMedGoogle Scholar
  82. 82.
    Nascimento LC, Strabelli BS, de Almeida FC, Rossato LM, Leite AM, de Lima RA. Mothers’ view on late postoperative pain management by the nursing team in children after cardiac surgery. Rev Lat Am Enfermagem. 2010;18(4):709–15.PubMedGoogle Scholar
  83. 83.
    Hartman DM, Medoff-Cooper B. Transition to home after neonatal surgery for congenital heart disease. MCN Am J Matern Child Nurs. 2012;37(2):95–100.PubMedCentralPubMedGoogle Scholar
  84. 84.
    Wray J, Sensky T. Psychological functioning in parents of children undergoing elective cardiac surgery. Cardiol Young. 2004;14(2):131–9.PubMedGoogle Scholar
  85. 85.
    Carayon P, Schoofs HA, Karsh BT, et al. Work system design for patient safety: the SEIPS model. Qual Saf Health Care. 2006;15 Suppl 1(1475–3898 (Linking)):i50–i58.Google Scholar
  86. 86.
    Davies JM. Painful inquiries: lessons from Winnipeg. CMAJ. 2001;165(11):1503–4.PubMedCentralPubMedGoogle Scholar
  87. 87.
    Kennedy I. Learning from Bristol: the report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984–1995. 2001. Command Paper: CM 5207.Google Scholar
  88. 88.
    Wiegmann DA, Eggman AA, Elbardissi AW, Parker SH, Sundt TM. Improving cardiac surgical care: a work systems approach. Appl Ergon. 2010;41(5):701–12.PubMedCentralPubMedGoogle Scholar
  89. 89.
    Barach P, Johnson JK, Ahmad A, et al. A prospective observational study of human factors, adverse events, and patient outcomes in surgery for pediatric cardiac disease. J Thorac Cardiovasc Surg. 2008;136(6):1422–8.PubMedGoogle Scholar
  90. 90.
    Elbardissi AW, Wiegmann DA, Dearani JA, Daly RC, Sundt TM. Application of the human factors analysis and classification system methodology to the cardiovascular surgery operating room. Ann Thorac Surg. 2007;83(4):1412–8.PubMedGoogle Scholar
  91. 91.
    Wiegmann DA, Elbardissi AW, Dearani JA, Daly RC, Sundt TM. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery. 2007;142(5):658–65.PubMedGoogle Scholar
  92. 92.
    Parker SE, Laviana AA, Wadhera RK, Wiegmann DA, Sundt TM. Development and evaluation of an observational tool for assessing surgical flow disruptions and their impact on surgical performance. World J Surg. 2010;34(2):353–61.PubMedGoogle Scholar
  93. 93.
    Carthey J, de Leval MR, Wright DJ, Farewell VJ, Reason JT. Behavioural markers of surgical excellence. Saf Sci. 2003;41:409–25.Google Scholar
  94. 94.
    Carthey J, de Leval MR, Reason JT. The human factor in cardiac surgery: errors and near misses in a high technology medical domain. Ann Thorac Surg. 2001;72(1):300–5.PubMedGoogle Scholar
  95. 95.
    de Leval MR, Carthey J, Wright DJ, Reason JT. Human factors and cardiac surgery: a multicenter study. J Thorac Cardiovasc Surg. 2000;119(4):661–72.PubMedGoogle Scholar
  96. 96.
    Bognar A, Barach P, Johnson JK, et al. Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac surgical teams. Ann Thorac Surg. 2008;85(4):1374–81.PubMedGoogle Scholar
  97. 97.
    Schraagen JM, Schouten T, Smit M, et al. Assessing and improving teamwork in cardiac surgery. Qual Saf Health Care. 2010;19(6):1–6.Google Scholar
  98. 98.
    Schraagen JM, Schouten T, Smit M, et al. A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes. BMJ Qual Saf. 2011;20(7):599–603.PubMedGoogle Scholar
  99. 99.
    Young-Xu Y, Neily J, Mills PD, et al. Association between implementation of a medical team training program and surgical morbidity. Arch Surg (Chicago, Ill: 1960). 2011;146(12):1368–73.Google Scholar
  100. 100.
    Catchpole KR. Task, team and technology integration in the paediatric cardiac operating room. Prog Pediatr Cardiol. 2011;32:85–8.Google Scholar
  101. 101.
    Catchpole KR, de Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth. 2007;17(5):470–8.PubMedGoogle Scholar
  102. 102.
    Nagpal K, Abboudi M, Fischler L, et al. Evaluation of postoperative handover using a tool to assess information transfer and teamwork. Ann Surg. 2011;253(4):831–7.PubMedGoogle Scholar
  103. 103.
    Zavalkoff SR, Razack SI, Lavoie J, Dancea AB. Handover after pediatric heart surgery: a simple tool improves information exchange. Pediatr Crit Care Med. 2011;12(3):309–13.PubMedGoogle Scholar
  104. 104.
    Catchpole K, Sellers R, Goldman A, McCulloch P, Hignett S. Patient handovers within the hospital: translating knowledge from motor racing to healthcare. Qual Saf Health Care. 2010;19(4):318–22.PubMedGoogle Scholar
  105. 105.
    Catchpole KR, Gangi A, Blocker RC, et al. Flow disruptions in trauma care handoffs. J Surg Res. 2013;184(1):586–91.PubMedGoogle Scholar
  106. 106.
    Pickering SP, Robertson ER, Griffin D, et al. Compliance and use of the World Health Organization checklist in UK operating theatres. Br J Surg. 2013;100(12):1664–70.PubMedGoogle Scholar
  107. 107.
    Bion J, Comm W, Richardson A, et al. ‘Matching Michigan’: a 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. BMJ Qual Saf. 2013;22(2):110–23.PubMedCentralPubMedGoogle Scholar
  108. 108.
    Dixon-Woods M, Leslie M, Tarrant C, Bion J. Explaining Matching Michigan: an ethnographic study of a patient safety program. Implement Sci. 2013;8:13.Google Scholar
  109. 109.
    Nemeth C, Wears RL, Patel S, Rosen G, Cook R. Resilience is not control: healthcare, crisis management, and ICT. Cogn Technol Work. 2011;13(3):189–202.Google Scholar
  110. 110.
    Wachter RM. Patient safety at ten: unmistakable progress, troubling gaps. Health Affairs (Project Hope). 2010;29(1):165–73.Google Scholar
  111. 111.
    Smith GCS, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. Br Med J. 2003;327(7429):1459–61.Google Scholar

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© Springer-Verlag London 2015

Authors and Affiliations

  1. 1.Department of SurgeryCedars-Sinai Medical CenterLos AngelesUSA

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