First Reported Use of Team Cognitive Workload for Root Cause Analysis in Cardiac Surgery

Marco A. Zenati*, Kay B. Leissner, Suzana Zorca, Lauren Kennedy-Metz, Steven J. Yule, Roger D. Dias

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

Abstract / Description of output

Cognitive workload data of members of the cardiac surgery team can be measured intraoperatively and stored for later analysis. We present a case of a near-miss (medication error) that underwent root cause analysis using workload data. Heart rate variability data, representing workload levels, were collected from the attending surgeon, attending anesthesiologist, and lead perfusionist using wireless heart rate monitors. An episode of cognitive overload of the anesthesiologist due to a distractor was associated with the preventable error. Additional studies are needed to better understand the role of psychophysiological data in enhancing surgical patient safety.

Original languageEnglish
Pages (from-to)394-396
Number of pages3
JournalSeminars in Thoracic and Cardiovascular Surgery
Issue number3
Early online date19 Dec 2018
Publication statusPublished - 1 Sept 2019

Keywords / Materials (for Non-textual outputs)

  • Cardiac surgery
  • Cognitive workload
  • Heart rate variability
  • Root cause analysis
  • Team workload


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