Second Safety Measure during Cardiac Surgery

The highly skilled and dedicated personal in cardiac ORs are human and will make errors. One third of deaths associated with Coronary Bypass Graft (CABG) operations may be preventable [1]. The two areas have been the focus: techniques and nontechnical skills such as communication, cooperation, coordination and leadership [2]. We call those the first safe Measure. Despite those efforts, there is little progress achieved in reducing or preventing errors 14 years after the Institution of Medicine report [1]. Therefore, the second safety measure is warranted. We present a case to highlight the needs of “second safety measure” during cardiac surgery.