Bottlenecks and needs in human-human and human-machine interaction - a view from and into the neurosurgical OR.

The number and complexity of user interfaces in the OR has been considerably increasing during the last years. Moreover, increasing cost and time pressure force surgeons and surgical nurses to perform different tasks in parallel. We analyzed the workflow of 25 neurosurgical procedures with a workflow analysis tool in order to analyze the present situation in the neurosurgical OR and to identify potential use-oriented risks and to develop first proposals for respective countermeasures. Application of the navigation system, the CUSA ultrasonic aspirator, and the PACS-PC was associated with errors and resulting potential risks. A number of different disruptive factors have been identified, the most prominent of those being intraoperative duty phone calls, longer absence of the circulating nurses or slipped off foot switches. Furthermore, the identified problems may lead to risks for patient, and also for staff by use errors, associated with an inappropriate cognitive workload of the surgeon or nurses. Organizational and technical countermeasures are necessary: to enhance communication, team trainings could be helpful, and the setup of a mailbox could reduce the number of intraoperative duty phone calls. Technical deficiencies have to be reduced, e.g. with more user-oriented design of devices, such as foot switches, or standard design for user interfaces. For further risk reduction in the case of use deficiencies, we propose the implementation of device interoperability and the use of a sterile integrated user interface in a networked OR.