Table 3.

Illustrative Examples of Factors

A. Contributing Factors
	Factor	Example
Patient	Anatomy	Patient’s obesity prolongs entry into the abdomen and hinders pelvic exposure.
	Physiology	Patient has a vagal response to intra-abdominal manipulation.
Providers	Monitoring/Vigilance	Surgeons do not notice that anesthesiologists are troubleshooting the ventilator with Biomedical Engineering; they ask for the volume of their music to be increased.
	Knowledge/Training	Trainee inexperienced at central line placement punctures the carotid artery.
	Leadership	Surgical resident contacts attending 3 times for help; he does not scrub until 28 minutes after incision.
	Communication	Anesthesiology resident misinterprets surgeons’ claims of “no surgical bleeding” to mean there is no bleeding; resuscitation lags.
	Coordination	Attending surgeon’s absence stalls progress; team is unsure about supplies and/or surgical approach and is unable to prepare and/or start.
	Cooperation	Surgeons are unresponsive to anesthesiologists’ announcement that the patient’s blood pressure has dropped; they do not engage in problem-solving.
Environment/Organization	Equipment	Equipment malfunction and patient monitors share the same alert signal; users cannot distinguish between malfunction and patient instability based on the sound of the alarm.
	Organization	During a case complicated by patient obesity, a scrub technician notes that longer instruments were requested 6 months ago by another surgeon and never acquired.
	Communication	Laboratory work drawn in pre-admission testing returns with abnormal results, but is not seen or addressed until the day of surgery because there is no system by which such results are checked and/or communicated. The case is delayed while the tests are repeated and specialists consulted.
	Coordination	The number of ongoing oncology cases is greater than the number of available oncology nurses or oncology kits. A delay results, as unfamiliar nurses attempt to assemble a kit from the pieces of other kits.

B. Compensatory Factors
	Factor	Example
Patient	Physiology	Patient weans off of his nitroglycerin drip before leaving the room.
Providers	Monitoring/Vigilance	Pod nurse enters the room during induction and realizes the scrub technician is missing. He scrubs in his place to prevent a delay.
	Knowledge/Training	Attending anesthesiologist recognizes the critical nature of the case and accelerates resuscitation.
	Leadership	An alarm sounds, and the nursing and anesthesiology teams become absorbed in searching for its source, leaving their posts. The circulator sends everyone back to work and contacts Biomedical Engineering.
	Adaptability	The urology team is unaware that a patient was booked for stents prior to his colorectal resection, but, upon being contacted, agrees to come immediately. The nurses, anesthesiology resident, and surgical resident halt their tasks to help him.
	Communication	Surgeon goes to Pathology himself to orient them to the specimen. His insistence on synchronous communication reduces the length of time required for pathological determination of the margins.
	Coordination	Plastic surgery is scheduled to close the abdomen. Primary surgeon gives the plastic surgery team ample advance notice, both pre- and intra-operatively.
	Cooperation	When asked by the anesthesiology resident, the surgeons remove all instruments from the abdomen until the patient stabilizes.
	Contingency Planning	After an episode of bleeding during which a scrub technician had difficulty finding the requested instruments, the surgeon instructs him as to which ones to have ready in the future.