Date of Award

Summer 2013

Access Type

Thesis - Open Access

Degree Name

Master of Science in Human Factors & Systems


Human Factors and Systems

Committee Chair

Albert J. Boquet, Ph.D.

First Committee Member

Jason P. Kring, Ph.D.

Second Committee Member

Douglas A. Wiegmann, Ph.D.


The operating room is one of the most complex work environments in healthcare; it is estimated that at least 7% of adverse events due to medical error occur in the operating room. Flow disruptions are events that cause a "break" in the primary surgical task, or the loss of any team member's situational awareness. An empirical link between flow disruptions and surgical errors in the OR has been established; therefore, identifying and classifying the specific flow disruptions present during different types of procedures should facilitate the development of evidence-based interventions. The goal of this study was to identify and classify flow disruptions during laparoscopic cholecystectomy (camera-assisted gallbladder removal) and open inguinal and umbilical hernia repair procedures. Results of this study revealed seven categories of disruption that emerged inductively from the data collected. These were: communication, coordination, external/extraneous source, training/supervisory, equipment/supplies, patient factors, and environment. Though the average duration and disruption rate were similar for both types of procedure, the type of disruptions present during each were unique. One example of this includes the higher incidence of equipment related flow disruptions during laparoscopic cholesystechtomies, which is the more equipment intensive procedure of the two observed.