Root cause analysis of safety incidents in antineoplastic use in children.

OBJECTIVES: to identify and analyze the factors that contribute to safety incident occurrence in the processes of prescribing, preparing and dispensing antineoplastic medications in pediatric oncology patients. METHODS: a quality improvement study focused on oncopediatric pharmaceutical care processes that identified and analyzed incidents between 2019-2020. A multidisciplinary group performed root cause analysis (RCA), identifying main contributing factors. RESULTS: in 2019, seven incidents were recorded, 57% of which were prescription-related. In 2020, through active search, 34 incidents were identified, 65% relating to prescription, 29% to preparation and 6% to dispensing. The main contributing factors were interruptions, lack of electronic alert, work overload, training and staff shortages. CONCLUSIONS: the results showed that adequate recording and application of RCA to identified incidents can provide improvements in the quality of pediatric oncology care, mapping contributing factors and enabling managers to develop an effective action plan to mitigate risks associated with the process.

Validity of root cause analysis in investigating adverse events in psychiatry.

Root cause analysis (RCA), imported from high-reliability industries into health two decades ago, is the mandated methodology to investigate adverse events in most health systems. In this analysis, we argue that the validity of RCA in health and in psychiatry must be established, given the impact of these investigations on mental health policy and practice.

Delays in Diagnosis, Treatment, and Surgery: Root Causes, Actions Taken, and Recommendations for Healthcare Improvement.

OBJECTIVES: Although patient safety continues to be a priority in the U.S. healthcare system, delays in diagnosis, treatment, or surgery still led to adverse events for patients. The purpose of this study was to review root cause analysis (RCA) reports in the Veterans Health Administration to identify the root causes and contributing factors of delays in diagnosis, treatment, or surgery in an effort to prevent avoidable delays in future care. METHODS: The RCA reports from Veterans Health Administration hospitals from October 2016 through September 2019 were reviewed and the root causes and contributory factors were identified. These elements were coded by consensus and analyzed using descriptive statistics. RESULTS: During the 3-year study period, 206 RCAs were identified and 163 were analyzed that were specific to delays in diagnosis, treatment, and surgery. The reports identified 24 delays in diagnosis, 117 delays in treatment, and 22 delays in surgery. Delays occurred most often in outpatient settings. CONCLUSIONS: Results supported the need for standardization of care processes and procedures, improved communication between and within department personnel, and improved policies and procedures that will be followed as intended. By reviewing adverse events, root causes, and contributing factors identified by local RCA teams, strategies can be developed to reduce delays in diagnosis and treatment of patients and lead to safer care.

Root-cause Analysis of Mortality After Pancreatic Resection (CARE Study): A Multicenter Cohort Study.

OBJECTIVES: Analyze a multicenter cohort of deceased patients after pancreatectomy in high-volume centers in France by performing a root-cause analysis (RCA) to define the avoidable mortality rate. BACKGROUND: Despite undeniable progress in pancreatic surgery for over a century, postoperative outcome remains particularly worse and could be further improved. METHODS: All patients undergoing pancreatectomy between January 2015 and December 2018 and died postoperatively within 90 days after were included. RCA was performed in 2 stages: the first being the exhaustive collection of data concerning each patient from preoperative to death and the second being blind analysis of files by an independent expert committee. A typical root cause of death was defined with the identification of avoidable death. RESULTS: Among the 3195 patients operated on in 9 participating centers, 140 (4.4%) died within 90 days after surgery. After the exclusion of 39 patients, 101 patients were analyzed. The cause of death was identified in 90% of cases. After RCA, mortality was preventable in 30% of cases, mostly consequently to a preoperative assessment (disease evaluation) or a deficient postoperative management (notably pancreatic fistula and hemorrhage). An inappropriate intraoperative decision was incriminated in 10% of cases. The comparative analysis showed that young age and arterial resection, especially unplanned, were often associated with avoidable mortality. CONCLUSIONS: One-third of postoperative mortality after pancreatectomy seems to be avoidable, even if the surgery is performed in high volume centers. These data suggest that improving postoperative pancreatectomy outcome requires a multidisciplinary, rigorous, and personalized management.

Half of Postoperative Deaths After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Could be Preventable: A French Root Cause Analysis on 5562 Patients.

OBJECTIVE: To perform a retrospective root-cause analysis of postoperative death after CRS and HIPEC procedures. BACKGROUND: The combination of CRS and HIPEC is an effective therapeutic strategy to treat peritoneal surface malignancies, however it is associated with significant postoperative mortality. METHODS: All patients treated with a combination of CRS and HIPEC between January 2009 and December 2018 in 22 French centers and died in the hospital, were retrospectively analyzed. Perioperative data of the 101 patients were collected by a local senior surgeon with a sole junior surgeon. Three independent experts investigated the typical root cause of death and provided conclusions on whether postoperative death was preventable (PREV group) or not (NON-PREV group). A typical root cause of preventable postoperative death was classified on a cause-and-effect diagram. RESULTS: Of the 5562 CRS+HIPEC procedures performed, 101 in-hospital deaths (1.8%) were identified, of which a total of 18 patients of 70 years old and above and 20 patients with ASA score of 3. Etiology of peritoneal disease was mainly colorectal. A total of 54 patients (53%) were classified in the PREV group and 47 patients (47%) in the NON-PREV group. The results of the study show that in the PREV group, WHO performance status 1-2 was more frequent and the Median Peritoneal Cancer Index was higher compared with those of the NON-PREV group. The cause of death in the PREV group was classified as: (i) preoperatively for debatable indication (59%), (ii) intraoperatively (30%) and (iii) postoperatively in 17 patients (31%). A multifactorial cause of death was found in 11 patients (20%). CONCLUSION: More than half of the postoperative deaths after combined CRS and HIPEC may be preventable, mainly by following guidelines regarding preoperative selection of the patients and adequate intraoperative decisions.

Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries.

INTRODUCTION: Many hospital settings are adopting a zero-tolerance policy towards pressure injury (PI) development; this requires good planning and the implementation of care, as the incidence of PIs reflects the quality of care given in a hospital or facility. AIM: To identify common contributing factors towards the development of PIs in a geriatric rehabilitation hospital and improve patient safety through the reduction of hospital-acquired PIs. METHOD: This was done using root cause analysis (RCA). All patients who developed a Stage 3 or 4 deep tissue injuries or unstageable hospital-acquired PI between December 2017 and April 2018 PIs were investigated using RCA. The RCA was facilitated through the use of a contributing framework developed by the National Pressure Ulcer Advisory Panel which guides investigations of different areas of care. Qualitative and quantitative data was collected from several sources and placed in a timeline to reconstruct the series of events. The investigator then identified if the PI was avoidable or not by comparing the evidence with pre-set criteria. Content analysis was further used to analyse the themes retrieved. RESULTS: A variety of root causes were common amongst all the cases. These included both flaws in the system, such as poor equipment and inadequate educational programmes, as well as human factors such as a lack of basic routine care. No skin assessment was being performed (n = 0) apart from the assessment done on admission. Documentation of action planning when it comes to PI prevention was also missing (n = 0). It was identified that 7 patients were mobilized on admission while the others (n = 3) had a delay in mobilisation, due to some fragmentation in care. There was no documentation of patient and relative education on the prevention of PIs (n = 0). All the patients were provided with the right pressure redistributing mattress however, some mattresses were bottoming out. Some causes overlapped, with system defects like lack of protocols, equipment and tools pushing human errors to occur. This created a series of events leading to the adverse event. The identification of these factors helped to provide an understanding of the changes that are needed to reduce future harm and improve patient safety. CONCLUSION: Recommendations were proposed to reduce contributing factors to the development of hospital-acquired PIs. These include audits to reinforce adherence to hospital guidelines, streamlining of the documentation system, investment in new equipment and improvements to educational programmes. The recommendations implemented resulted in a decreased incidence rate of HAPIs.

Association of diabetes with frequency and cost of hospital admissions: a retrospective cohort study.

BACKGROUND: Acute inpatient hospital admissions account for more than half of all health care costs related to diabetes. We sought to identify the most common and costly conditions leading to hospital admission among patients with diabetes compared with patients without diabetes. METHODS: We used data from the General Internal Medicine Inpatient Initiative (GEMINI) study, a retrospective cohort study, of all patients admitted to a general internal medicine service at 7 Toronto hospitals between 2010 and 2015. The Canadian Institute for Health Information (CIHI) Most Responsible Diagnosis code was used to identify the 10 most frequent reasons for admission in patients with diabetes. Cost of hospital admission was estimated using the CIHI Resource Intensity Weight. Comparisons were made between patients with or without diabetes using the Pearson χ2 test for frequency and distribution-free confidence intervals (CIs) for median cost. RESULTS: Among the 150 499 hospital admissions in our study, 41 934 (27.8%) involved patients with diabetes. Compared with patients without diabetes, hospital admissions because of soft tissue and bone infections were most frequent (2.5% v. 1.9%; prevalence ratio [PR] 1.28, 95% CI 1.19-1.37) and costly (Can$8794 v. Can$5845; cost ratio [CR] 1.50, 95% CI 1.37-1.65) among patients with diabetes. This was followed by urinary tract infections (PR 1.16, 95% CI 1.11-1.22; CR 1.23, 95% CI 1.17-1.29), stroke (PR 1.13, 95% CI 1.07-1.19; CR 1.19, 95% CI 1.14-1.25) and electrolyte disorders (PR 1.11, 95% CI 1.03-1.20; CR 1.20, 95% CI 1.08-1.34). INTERPRETATION: Soft tissue and bone infections, urinary tract infections, stroke and electrolyte disorders are associated with a greater frequency and cost of hospital admissions in patients with diabetes than in those without diabetes. Preventive strategies focused on reducing hospital admissions secondary to these disorders may be beneficial in patients with diabetes.

The RCA ReCAst: A Root Cause Analysis Simulation for the Interprofessional Clinical Learning Environment.

PROBLEM: The Accreditation Council for Graduate Medical Education calls for resident participation in real or simulated interprofessional analysis of a patient safety event. There are far more residents who must participate in these investigations than available institutional root cause analyses (RCAs) to accommodate them. To correct this imbalance, the authors developed an institutionally sponsored, interprofessional RCA simulation program and implemented it across all graduate medical education (GME) residency programs at the Hospital of the University of Pennsylvania. APPROACH: The authors developed RCA simulations based upon authentic adverse events experienced at their institution. To provide relevance to all GME programs, RCA simulation cases varied widely and included examples of errors involving high-risk medications, communication, invasive procedures, and specimen labeling. Each simulation included residents and other health care professionals such as nurses or pharmacists whose disciplines were involved in the actual event. Participants adopted the role of RCA investigation team, and in small groups systematically progressed through the RCA process. OUTCOMES: A total of 289 individuals from 18 residency programs participated in an RCA simulation in 2019-2020. This included 84 interns (29%), 123 residents (43%), 20 attending physicians (7%), and 62 (21%) other health care professionals. There was an increase in ability of GME trainees to correctly identify factors required for an RCA investigation (62% pre vs 80% post, P = .02) and an increase in intent to "always report" for each adverse event category (3% pre vs 37% post, P < .001) following the simulation. NEXT STEPS: The authors plan to expand the RCA simulation program to other GME clinical sites while striving to involve all GME learners in this educational experience at least once during training. Additionally, by collaborating with health system patient safety leaders, they will annually review all new RCAs to identify cases suitable for simulation adaptation.

Evaluation of Learning Teams Versus Root Cause Analysis for Incident Investigation in a Large United Kingdom National Health Service Hospital.

INTRODUCTION: Significant resource is invested into investigation of adverse healthcare events. Outcomes of such investigations have varying degrees of effectiveness. The "hierarchy of effectiveness" model proposes system-focused changes have greater impact than person-focused actions. The traditional approach to investigation is root cause analysis (RCA); however, such an approach does not prioritize system-focused action generation. Learning team-based investigations are thought to generate more effective system-focused actions; however, this has not been evaluated. METHODS: Retrospective mixed methods evaluation of learning teams compared with RCA. Twenty-two learning team investigations compared with 22 RCA investigations, with quantitative assessment of the number of system-focused and person-focused actions generated. Assignment of the two different methods to incidents was not random, with learning teams being selected for cases, which were initially judged to be process-focused problems. Semistructured interviews were conducted with four learning team facilitators with thematic analysis to identify causes for outcome variations. RESULTS: Learning team investigations yielded a median of 7.5 actions compared with 3.5 actions for RCA: 57% of learning team actions were system focused versus 30% for RCA. We identified variations in personnel involved, culture of the investigation, and differences in the investigative approaches as potential drivers for these differences. CONCLUSIONS: We observed that learning team investigations that targeted process-focused problems generated more actions and a higher number of system-focused actions. There is a difference in culture created during learning team investigations. Although learning teams are not suitable for all investigations, they represent a readily reproducible and valuable addition to the investigative toolkit.

Improving the Effectiveness of Root Cause Analysis in Hospitals.

Improving patient safety within hospitals has become a major focal point for administrative and clinical action. Root Cause Analysis (RCA) is an analytical tool used by hospitals in quality improvement and patient safety efforts. While hospitals have widely embraced RCA, the effectiveness of the RCA process has been questioned in recent years. Based on a literature review and feedback from practicing administrators, this paper identifies current barriers to the effectiveness of the RCA process, and suggests actions to overcome them. A more effective RCA process will enable hospitals to establish a safer and more trustworthy care environment for patients.

Preimplantation genetic testing as a component of root cause analysis of errors and reassignment of embryos in IVF.

The risks of embryo/gamete mix-up are a threat to the integrity of the IVF process, with significant implications for affected families. The use of preimplantation genetic testing through single-nucleotide polymorphism array or next-generation sequencing technology can help to identify, characterize and ultimately help, in some cases, to find the root cause, and to mitigate the extent of these errors for a given patient or laboratory.

Assisting beginners in root cause analysis operations: analysis and recommendations regarding the spread of COVID-19 in nursing facilities for the elderly.

BACKGROUND: To analyse a medical accident, much time and experience are needed. However, people without experience in analysis have difficulty understanding its conditions and methods, and as a result it takes longer to establish countermeasures. It must be noted that understanding conditions by simply aligning occurrences in the accident in a chronological order is difficult. PURPOSE: A workflow chart that considers time was proposed so that individuals without adequate experience in analysis could easily carry out root cause analysis. METHODS: In the 'workflow chart (WFC)', the time sequence was described horizontally. On the vertical axis, the business manual, the occurrence of the accident, and the time of the occurrence are displayed. In the bottom column of patient event, information regarding damage to patients was written in accordance with time axis. Regarding the degree of damage, the time of error until the accident was identified was connected using a straight line (when the patient was not affected, a dotted line was used) in order to show the overall picture of the accident. RESULTS: According to the time flow chart, hints to identify potential risks were proposed. Focus was placed not only on the error event, but also on keywords such as manual inadequacy, time gap, degree of error and so on to easily lead to the question 'why?' To visualise this, I proposed an operation flow chart. By using time-WFC, even beginners can easily develop accident countermeasure strategies. CONCLUSION: Using a WFC that considers time, time of error and the occurrence of accident could be visualised. As a result, even individuals without experience in analysis could easily perform an analysis.

Nondiagnostic fine-needle aspirates of the pancreas: A root cause analysis.

BACKGROUND: Fine-needle aspiration (FNA) of the pancreas is considered the primary and least invasive diagnostic method in the evaluation of pancreatic lesions. A nondiagnostic sample may trigger repeat FNA or a more invasive diagnostic procedure. The goal of this study was to identify the root causes of nondiagnostic samples. METHODS: We performed a retrospective review of FNAs of the pancreas categorized as nondiagnostic at our institution between 2008 and 2019. Medical records and slides were reviewed to identify the features described by imaging, rapid on-site evaluation, fluid chemistry, final cytology diagnosis, and final histology. A root cause analysis was performed using the Ishikawa (or fishbone) diagram and the 5 Whys method. RESULTS: A total of 30 cases were identified: 11 adenocarcinomas, 6 cases of pancreatitis, 4 intraductal papillary mucinous neoplasms, 3 serous cystadenomas, 3 neuroendocrine tumors, 1 mucinous cystic neoplasm, 1 retention cyst, and 1 case of Brunner gland hyperplasia. The root causes identified were: man in 8 cases, machine in 1 case, method in 17 cases, and material in 18 cases. In many cases, more than 1 root cause contributed to the problem. CONCLUSION: Material related errors contributed to the majority of nondiagnostic results and were primarily related to fibrotic cancers, chronic pancreatitis, absence of diagnostic criteria of cystic lesions, and technically challenging cases. Only 1 major interpretation error was identified. Sampling and interpretive errors contributed equally to man-related causes. For mucinous cysts, neoplastic mucin was difficult to identify in liquid-based preparations. Pathologists tended to issue a nondiagnostic categorization when epithelial cells are lacking and particularly when the nature and radiological impression of the cyst was not communicated.

Assessment of Health Information Technology-Related Outpatient Diagnostic Delays in the US Veterans Affairs Health Care System: A Qualitative Study of Aggregated Root Cause Analysis Data.

Importance: Diagnostic delay in the outpatient setting is an emerging safety priority that health information technology (HIT) should help address. However, diagnostic delays have persisted, and new safety concerns associated with the use of HIT have emerged. Objective: To analyze HIT-related outpatient diagnostic delays within a large, integrated health care system. Design, Setting, and Participants: This cohort study involved qualitative content analysis of safety concerns identified in aggregated root cause analysis (RCA) data related to HIT and outpatient diagnostic delays. The setting was the US Department of Veterans Affairs using all RCAs submitted to the Veterans Affairs (VA) National Center for Patient Safety from January 1, 2013, to July 31, 2018. Main Outcomes and Measures: Common themes associated with the role of HIT-related safety concerns were identified and categorized according to the Health IT Safety framework for measuring, monitoring, and improving HIT safety. This framework includes 3 related domains (ie, safe HIT, safe use of HIT, and using HIT to improve safety) situated within an 8-dimensional sociotechnical model accounting for interacting technical and nontechnical variables associated with safety. Hence, themes identified enhanced understanding of the sociotechnical context and domain of HIT safety involved. Results: Of 214 RCAs categorized by the terms delay and outpatient submitted during the study period, 88 were identified as involving diagnostic delays and HIT, from which 172 unique HIT-related safety concerns were extracted (mean [SD], 1.97 [1.53] per RCA). Most safety concerns (82.6% [142 of 172]) involved problems with safe use of HIT, predominantly sociotechnical factors associated with people, workflow and communication, and a poorly designed human-computer interface. Fewer safety concerns involved problems with safe HIT (14.5% [25 of 172]) or using HIT to improve safety (0.3% [5 of 172]). The following 5 key high-risk areas for diagnostic delays emerged: managing electronic health record inbox notifications and communication, clinicians gathering key diagnostic information, technical problems, data entry problems, and failure of a system to track test results. Conclusions and Relevance: This qualitative study of a national RCA data set suggests that interventions to reduce outpatient diagnostic delays could aim to improve test result management, interoperability, data visualization, and order entry, as well as to decrease information overload.

Root cause analysis of pre-microscopic errors in anatomical pathology using Eindhoven classification.

OBJECTIVE: To evaluate pre-microscopic errors in anatomical pathology. METHODS: The cross-sectional descriptive study was conducted at the Department of Pathology of a tertiary care hospital in Lahore, Pakistan, from September, 2016, to January, 2017, and comprised surgical pathology specimens. Errors were noted across the pre-microscopic process. Defects per million opportunities were calculated to determine sigma metric value in every step, from requisition to slide preparation. Root cause analysis was applied to the process of histology preparation to identify the root cause of each previously identified problem using Eindhoven classification. All errors were recorded on a pre-designed proforma. RESULTS: There were 2420 specimens. While errors were encountered in all phases of the pre-microscopic process, but the (G6: n=1085, 44.83%), followed by requisition (R3: n=893, 36.9%) and cover slipping (C1: n=776, 32.06%). CONCLUSIONS: Development of standard procedures and protocols with staff training is likely to help in controlling the errors.

A qualitative content analysis of retained surgical items: learning from root cause analysis investigations.

OBJECTIVE: To describe incidents of retained surgical items, including their characteristics and the circumstances in which they occur. DESIGN: A qualitative content analysis of root cause analysis investigation reports. SETTING: Public health services in Victoria, Australia, 2010-2015. PARTICIPANTS: Incidents of retained surgical items as described by 31 root cause analysis investigation reports. MAIN OUTCOME MEASURE(S): The type of retained surgical item, the length of time between the item being retained and detected and qualitative descriptors of the contributing factors and the circumstances in which the retained surgical items occurred. RESULTS: Surgical packs, drain tubes and vascular devices comprised 68% (21/31) of the retained surgical items. Nearly one-quarter of the retained surgical items were detected either immediately in the post-operative period or on the day of the procedure (7/31). However, about one-sixth (5/31) were only detected after 6 months, with the longest period being 18 months. Contributing factors included complex or multistage surgery; the use of packs not specific to the purpose of the surgery; and design features of the surgical items. CONCLUSION: Retained drains occurred in the post-operative phase where surgical counts are not applicable and clinician situational awareness may not be as great. Root cause analysis investigation reports can be a valuable means of characterizing infrequently occurring adverse events such as retained surgical items. They may detect incidents that are not detected by other data collections and can inform the design enhancements and development of technologies to reduce the impact of retained surgical items.

Preventing slips, overruns, and cancellations: Application of system accident investigations and theory to the understanding and prevention of engineering project failures.

Organizations that develop or operate complex engineering systems are plagued by systems engineering failures like schedule overruns, budget exceedances, and project cancellations. Unfortunately, there is not much actionable guidance on why these failures happen or how to prevent them. Our approach contains two novel aspects. First, we argue that system accidents and other failures in systems engineering are manifestations of similar underlying problems. Therefore, we can leverage the literature on accident causation and the many publicly available accident investigation reports to better understand how and why failures in systems engineering occur, and to identify ways of preventing them. Second, to address the lack of concrete guidance on identifying and preventing incipient failures, we provide specific examples of each type of failure cause and of the recommendations for preventing these causes. We analyzed a set of 30 accidents and 33 project failures, spanning a range of industries, and found 23 different failure causes, most of which appear in both accidents and other project failures, suggesting that accidents and project failures do happen in similar was. We also identified 16 different recommended remedial actions. We link these causes and recommendations in a cause-recommendation network, and associate over 900 specific examples of how these causes manifested in failures, and over 600 specific examples of the associated recommended remedial actions, with each cause or recommendation.

Using Safety-II and resilient healthcare principles to learn from Never Events.

OBJECTIVES: Conduct a secondary analysis of root cause analysis (RCA) reports of Never Events to determine whether and how Safety-II/resilient healthcare principles could contribute to improving the quality of investigation reports and therefore preventing future Never Events. DESIGN: Qualitative and quantitative retrospective analysis of RCA reports. SETTING: A large acute healthcare Trust in London. PARTICIPANTS: None. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Quality of RCA reports, robustness of actions proposed. RESULTS: RCA reports had low-to-moderate effectiveness ratings and low resilience ratings. Reports identified many system vulnerabilities that were not addressed in the actions proposed. Using a Safety-II/resilient healthcare lens to examine work-as-done and misalignments between demand and capacity would strengthen analysis of Never Events. CONCLUSION: Safety-II/Resilient Healthcare concepts can increase the quality of RCA reports and focus attention on prospectively strengthening systems. Recommendations for incorporating Safety-II concepts into RCA processes are provided.

Objective assessment of surgical operative performance by observational clinical human reliability analysis (OCHRA): a systematic review.

BACKGROUND: Both morbidity and mortality data (MMD) and learning curves (LCs) do not provide information on the nature of intraoperative errors and their mechanisms when these adversely impact on patient outcome. OCHRA was developed specifically to address the unmet surgical need for an objective assessment technique of the quality of technical execution of operations at individual operator level. The aim of this systematic review was to review of OCHRA as a method of objective assessment of surgical operative performance. METHODS: Systematic review based on searching 4 databases for articles published from January 1998 to January 2019. The review complies with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and includes original publications on surgical task performance based on technical errors during operations across several surgical specialties. RESULTS: Only 26 published studies met the search criteria, indicating that the uptake of OCHRA during the study period has been low. In 31% of reported studies, the operations were performed by fully qualified consultant/attending surgeons and by surgical trainees in 69% in approved training programs. OCHRA identified 7869 consequential errors (CE) during the conduct of 719 clinical operations (mean = 11 CEs). It also identified 'hazard zones' of operations and proficiency-gain curves (P-GCs) that confirm attainment of persistent competent execution of specific operations by individual trainee surgeons. P-GCs are both surgeon and operation specific. CONCLUSIONS: Increased OCHRA use has the potential to improve patient outcome after surgery, but this is a contingent progress towards automatic assessment of unedited videos of operations. The low uptake of OCHRA is attributed to its labor-intensive nature involving human factors (cognitive engineering) expertise. Aside from faster and more objective peer-based assessment, this development should accelerate increased clinical uptake and use of the technique in both routine surgical practice and surgical training.