Team Behavior and Patient Outcome Changes After Human Factors Program in a Pediatric Airway Setting

Pediatric airway endoscopy is a high-risk procedure requiring close coordination among multidisciplinary teams. Communication failures and deficiencies in nontechnical skills are major contributors to adverse events, while structured human factors training is not routinely embedded in pediatric surgical practice.

To evaluate whether a multimodal human factors training program improves operating room communication, team behavior, and nontechnical skills during pediatric laryngotracheal endoscopy.

This prospective quality improvement study with pretesting and posttesting was conducted at a tertiary university pediatric referral center over 3 consecutive phases: (1) pretesting of endoscopic procedures; (2) implementation of a human factors training program; and (3) posttesting. Team behaviors were assessed using observational metrics and the Non-Technical Skills for Surgeons (NOTSS) framework. Pediatric laryngotracheal endoscopic procedures were prospectively included. All procedures involved multidisciplinary teams including surgeons, anesthesiologists, and nursing staff. Data were collected from November 2021 to February 2023, and data were analyzed from September 2023 to March 2025.

A multimodal human factors training program combining a structured preoperative checklist, personalized identification caps, and simulation-based training inspired by aviation crew resource management.

Primary outcomes included adherence to communication practices, task interruptions, noise distribution, and NOTSS scores. Secondary outcomes included selected clinical indicators.

A total of 80 pediatric laryngotracheal endoscopic procedures, including 44 before and 36 after program implementation, were included. Of 71 included patients, the median (range) age was 3.4 years (18 days to 17.8 years). Verbal use of the national surgical checklist increased from 9.1% (4 of 44) to 88.9% (32 of 36) after the intervention (difference, 79.8 percentage points; 95% CI, 61.2-88.5). Preoperative discussions between the surgeon and anesthesiologist occurred in 31 of 44 cases (70.5%) before the program vs 36 of 36 (100%) afterward (difference, 29.5 percentage points; 95% CI, 14.6-29.5), and postoperative debriefings increased from 56.8% (25 of 44) to 91.7% (33 of 36; difference, 34.8 percentage points; 95% CI, 15.8-43.2). Following the program, identification of key procedural phases was improved; task interruptions, particularly door openings and phone calls during critical phases, were reduced; noise levels became more evenly distributed; and overall NOTSS scores increased. There was no difference in incidence of oxygen desaturation and atropine use.

This quality improvement study found that a structured human factors training program improved communication, coordination, and nontechnical skills during pediatric airway endoscopy, corresponding to a Kirkpatrick level 3 behavioral change. Although clinical outcomes were unchanged, observed behavioral and environmental improvements support a cultural shift in the operating room and justify integrating human factors education into pediatric surgical training programs.