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Implementation of a “threat and error” model in complex neonatal cardiac surgery patients to identify quality improvement opportunities

  • Deanna R. Todd Tzanetos (a1), Vicki Montgomery (a1), William Harrington (a2) and Aaron Calhoun (a1)



Neonates undergoing surgery for congenital heart disease are vulnerable to adverse events. Conventional quality improvement processes centring on mortality and significant morbidity leave a gap in the identification of systematic processes that, though not directly linked to an error, may still contribute to adverse outcomes. Implementation of a multidisciplinary “flight path” process for surgical patients may be used to identify modifiable threats and errors and generate action items, which may lead to quality improvement.


A retrospective review of our neonatal “flight path” initiative was performed. Within 72 hours of a cardiac surgery, a meeting of the multidisciplinary patient care team occurs. A “flight path” is generated, graphically illustrating the patient’s hospital course. Threats, errors, or unintended consequences are identified. Action items are generated, and a working group is formed to address the items. A patient’s flight path is updated weekly until discharge. The errors and action items are logged into a database, which is analysed quarterly to identify trends.


Thirty one patients underwent flight path review over a 1-year period; 22.5% (N = 7) of patients had an error-free “flight.” Eleven action items were generated – four from identified errors and seven from identified threats. Nine action items were completed.


Flight path reviews of congenital cardiac patients can be generated with few resources and aid in the detection of quality improvement opportunities. The regular multidisciplinary meetings that occur as a part of the flight path review process can promote inter-professional teamwork.


Corresponding author

Author for correspondence: Deanna Todd Tzanetos, MD, MSCI, 571 S. Floyd St. Suite 332 Louisville, KY40202, USA. Tel: +1 502 852 8633; Fax: +1 502 852 3998; E-mail:


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Implementation of a “threat and error” model in complex neonatal cardiac surgery patients to identify quality improvement opportunities

  • Deanna R. Todd Tzanetos (a1), Vicki Montgomery (a1), William Harrington (a2) and Aaron Calhoun (a1)


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