This study, conducted by Cohen and colleagues, examined the role of human factors (HF) and environmental challenges in intraoperative deaths (IDs) over a 12-year period at a single center. The researchers performed a retrospective analysis of staff-submitted incident reports related to IDs, categorizing contributing factors using a modified version of the Human Factors Analysis and Classification System.

The study's findings revealed that the top systemic failures contributing to IDs were teamwork coordination issues, skill-based errors, and physical environment problems. The research also identified significant gaps in knowledge and reporting, noting that only 16.3% of submitted incident reports addressed any type of work-system factors. Given the severity of adverse events and IDs, the authors suggest that a new paradigm or technique may be necessary to better track intraoperative work-system interactions and enable more effective root cause analyses of intraoperative adverse events.