ABSTRACT
This chapter provides a conservative estimate of the likely incidence of intraoperative failures in orthopaedic surgery across the UK. Surgery sits at the apex of the healthcare service, which makes it ideal for understanding both human error and the systemic properties that predispose error, since the sources of problems observed inside the operating theatre can often be attributed to deficient elements of the system. Total knee replacement (TKR) surgery is an elective and proceduralized operation usually involving two surgeons, an anaesthetist, a scrub nurse, a circulating nurse and an anaesthetic nurse. To prepare for the observations, ten similar cases were studied by both researchers before data collection began, and a task analysis and procedural-based error-capture checklists were produced for TKR operations. Observing small, recurrent problems in the operating theatre makes it possible to identify prospectively latent failures within the system which are regularly mitigated for, but occasionally cause harm.
