Getting the right tools for the job: preparatory system configuration and active replanning in cardiac surgery

Successful cardiac surgery requires having the right tools for the job in the right place and at the right time, even in the face of unforeseen circumstances. We describe how cognitive and material resources in the activity system of the OR enable well-defined courses of action (through preparatory configuration) while dynamically accommodating unlikely events (through replanning). Using ethnographic data from observations and video recordings in the operating room, we describe the nature of distributed planning in a bounded activity system with defined cognitive and physical resources. We describe the role of preparatory configuration for accomplishing expected courses of action, and the role of active replanning to achieve goals in the face of unexpected circumstances or events. Using a specific case study to illustrate these phenomena, we discuss these findings and their relevance to patient safety.