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This aim of this research was to identify events in the operating theatre process (described as glitches) during elective orthopaedic operations. Two pairs of observers, each consisting of a clinician and a human factors professional, examined primary and revision hip and knee arthroplasties, arthroscopies and knee ligament reconstructions in two UK hospitals. The categorisation procedure revealed 11 key areas of glitches within the collected data. Observations of 42 operations revealed 314 glitches within the 11 categories. The rate of glitches per operation ranged from 1 to 18, with an average of 8 per operation. Most commonly observed were distractions, equipment design and technical process deviation issues. A coordinated intervention to address a range of areas could benefit the efficiency and safety of orthopaedic surgery, and there are benefits in considering the standardisation of observation studies in the operating room. Copyright 2011 by Human Factors and Ergonomics Society, Inc. All rights reserved.

Original publication




Journal article


Proceedings of the Human Factors and Ergonomics Society

Publication Date



685 - 689