Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical center

'Herding cats': A mixed methods investigation into the educational value of debriefing in operating theatres

AIM

The aim of the study was to explore the value of debriefing to enhance learning within operating theatres.

METHODS

A sequential mixed method study was undertaken at a local District General Hospital Trust in 2020. A total of 106 surveys were distributed to all multidisciplinary team members based in the trauma and orthopaedic theatres. Following the survey stage, 11 in-depth semi-structured qualitative interviews were undertaken with volunteers from the survey stage which included a range of health care professionals.

FINDINGS

Participants identified debriefing as a valuable tool for learning and reflection. However, significant barriers were identified, including lack of time and conflicting priorities. Some interviewees referred to the current debriefing process as a 'tick box' and a 'herding cats' exercise, attributing it to a lack of structure, leadership and organisational buy-in.

CONCLUSIONS

Debriefing in the operating theatre is a valuable tool for individual and team learning. However, formalising the structure of the debriefing, along with joint team and organisational commitment, was deemed vital in optimising the value of debriefings in the future.

Debriefing to improve interprofessional teamwork in the operating room: A systematic review

PURPOSE

Debriefing has been pivotal in medical simulation training, but its application to the real-world operating room environment has been challenging. We reviewed the literature on routine surgical debriefing with special reference to its implementation, barriers, and effectiveness.

DESIGN

Descriptive systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

METHODS

Inclusion criteria were papers pertaining to debriefing in routine surgical practice. Excluded were papers reporting simulation training. We searched Google Scholar, CINAHL, Web of Science Core Collection, PsychINFO, Medline, Embase, and ProQuest Theses & Dissertations Global. The last search was performed on March 14, 2022. Quality was assessed on a 21-point checklist adapted from a standard reporting guideline. Synthesis was descriptive.

FINDINGS

The search process resulted in 19 papers. Publication dates ranged from 2007-2022. Study methods included surveys, interviews, and analysis of administrative data. Five papers involved a specific intervention. Quality scores ranged from 12-19 out of 21. On synthesis, we identified five topics: explanations of how debriefing had been implemented; the value of coaching and audit; the learning dimensions of debriefing, both team learning and quality improvement at the organizational level; the effect of debriefing on patient safety or the organization's culture; and barriers to debriefing.

CONCLUSIONS

Successful implementation programs were characterized by strong commitment from management and support by frontline workers. Integration with administrative quality and safety processes, and information feedback to frontline workers are fundamental to successful debriefing programs.

CLINICAL RELEVANCE

Debriefing can improve teamwork, learning, and psychological safety but is difficult to practice in the operating room environment. It is relevant to review the benefits and barriers to debriefing, and to learn from the experience of others, in order to run better debriefing models in our own hospitals.

Using huddles to improve communication and teamwork in an instrument-processing department

Instrument-processing staff work in a fast-paced, high-risk environment and errors in any of their processes can have a significant effect on patient safety. Effective communication is essential to the maintenance of complex processes such as the cleaning, disinfection and sterilisation of surgical instruments. This article details a service improvement project that aimed to evaluate staff members' perceptions of teamwork and communication before and after the implementation of team huddles in an instrument-processing department. A questionnaire was used to survey staff perceptions of teamwork and communication before and after the implementation of team huddles. The huddles included the use of a huddle board to standardise their content. While the survey did not identify any significant differences in staff perceptions before and after the implementation of the huddles, the department leaders noted significant improvements in the attitudes and engagement of staff members. The service improvement project demonstrated that structured team huddles can improve morale and efficiencies within departments through enhanced collaboration and communication.

Sexual Harassment of Female Providers by Patients: a Qualitative Study

BACKGROUND

Sexual harassment of women is a pervasive problem. Prior studies found that sexual harassment of female providers by patients is common, but guidance on addressing this problem is limited.

OBJECTIVE

To understand the experiences of female providers with sexual harassment by patients with a focus on how practicing providers address these events.

DESIGN

Qualitative study using semi-structured interviews.

PARTICIPANTS

Twenty female, internal medicine providers, including resident physicians, staff physicians, and nurse practitioners at a large, urban, academic hospital in the USA.

APPROACH

Interviews were analyzed for themes.

KEY RESULTS

Two themes were explored: first, the experiences with sexual harassment and, second, the strategies to address sexual harassment. We coded four sub-themes regarding participant experiences: (1) their descriptions of the types of harassment, (2) the context of the event, (3) the impact of the harassment, and (4) their preparation to address the harassment. We coded seven sub-themes on strategies used by participants: (1) indirect strategies, (2) confrontation, (3) modifying the clinical encounter, (4) modifying self, (5) alerting others, (6) debrief, and (7) report.

CONCLUSION

Our qualitative study found that sexual harassment of female providers by patients is an ongoing problem, disruptive to the patient-provider relationship, and a possible threat to the well-being of both provider and patient. Formal training on how to address this problem was lacking, but all providers had developed or adapted strategies based on personal experiences or role modeling. Educating providers on strategies is an important next step to addressing this problem.

'Take 10 to talk about it': Use of a scripted, post-event debriefing tool in a neonatal intensive care unit

AIM

This study assessed the impact of a scripted, post-event debriefing tool in identifying logistical, procedural, personnel and performance obstacles and successes in a clinical setting. It was predicted that the debriefing tool would highlight the importance of routine debriefing following challenging clinical events.

METHODS

The study was conducted in a 22-bed neonatal intensive care unit at a tertiary hospital and involved all staff members in the perinatal service. The debriefing tool, a two-page form providing a structured, scripted approach, was used at the earliest opportunity after acute clinical deteriorations, emergency caesarean sections and any other critical events as decided by the neonatal team. Sessions were facilitated by either a nursing or medical member of the neonatal team. Following a 2-month trial, impact was measured via the comparison of before and after survey questions as well as review of a database of issues raised, subsequent actions and outcomes.

RESULTS

Significant, positive changes were observed for survey questions specific to the frequency of debriefing, team communication, provision of learning opportunities and identification of logistical, equipment and procedural issues. In addition, the database highlighted the significant positive impact in day-to-day practice as a result of changes initiated by the debriefing tool. All participants requested the unit to continue using the tool.

CONCLUSION

Scripted, post-event debriefing is achievable and valuable in the clinical setting. It encourages a supportive workplace culture and empowers team members to initiate practical change in their organisations.

Implementation of surgical debriefing programs in large health systems: an exploratory qualitative analysis

Background

The role of the “debrief” to address issues related to patient safety and systematic flaws in care is frequently overlooked. In our study, we interview surgical leaders who have developed successful strategies of debriefing within a comprehensive program of quality improvement.

Methods

Semi-structured interviews of four implementation leaders were performed. The observations, beliefs and strategies of surgical leaders are compared and contrasted. Common themes are identified related to program success and failure. Quality and safety researchers performed, coded and categorized the interviews and coordinated the analysis and interpretation of the results. The authors from the four institutions aided in interpretation and framing of the results.

Results

The debriefing programs evaluated were part of comprehensive quality improvement projects. Seven high-level themes and 24 subthemes were identified from the interviews. Themes related to leadership included early engagement, visible ongoing commitment and enforcement. Success appeared to depend upon meaningful and early debriefing feedback. The culture of safety that promoted success included a commitment to open and fair communication and continuous improvement.

There were many challenges to the success of debriefing programs. The loss of institutional commitment of resources and personnel was the instigating factor behind the collapse of the program at Michigan. Other areas of potential failure included communication issues and loss of early and meaningful feedback.

Conclusions

Leaders of four surgical systems with strong debriefing programs report success using debriefing to improve system performance. These findings are consistent with previously published studies. Success requires commitment of resources, and leadership engagement. The greatest gains may be best achieved by programs that provide meaningful debriefing feedback in an atmosphere dedicated to open communication.

'Never Events in Surgery': Mere Error or an Avoidable Disaster

Never events in surgery is not an uncommon occurrence. It is difficult to find any surgeon who never had an experience of one or another kind of mistake, committed while delivering the surgical care to the patient. Whatever the reports come out through news media or other sources are just a tip of iceberg. Collectively, its results, not only as a huge suffering and financial burden for the patients but also its impact on the operating surgeon and sometimes to related institute, are very far reaching and extremely negative. In spite of all of this, every one of us thinks this as an individual problem or one of the anecdotal media coverage. The aim of this study is to create an awareness among surgeon's fraternity and bring the attention of associations of surgeon bodies to this serious issue so that collective steps can be initiated to address it. In an attempt to find all the related information, an extensive search of literature in English language was performed using online search engines: PubMed NCBI database, Google search, and other digital sources available online. Error may be in the form of an act of commission, act of omission, error of planning, or error of execution, but whatever the reason, ultimate impacts are not less than disastrous, affecting individuals to global level. In addition to the enforcing authorities, all other stake holders should wake up and must take collective and comprehensive approach to create a safety system inside the health care organisations.

Quality improvement in pediatric surgery

PURPOSE OF REVIEW

The goal of this review is to provide updates on the evolution of conceptual definitions as they relate to quality in healthcare, existing measurement platforms for performance benchmarking in pediatric surgery, and available tools for quality improvement that are relevant to care of the pediatric surgical patient.

RECENT FINDINGS

The American College of Surgeon's National Surgical Quality Improvement Program-Pediatric has continued to evolve, now providing risk-adjusted safety outcomes data to over 70 hospitals and broadening its scope of quality measurement to include resource utilization and value-based metrics. Increasing use of checklists and other team-based communication tools show potential for making surgical care safer for children, and thoughtful application of quality improvement methods such as Lean methodology, six-sigma and others are helping to improve efficiency and increase healthcare value. Finally, efforts to define minimal resource standards for pediatric surgical care holds promise to improve outcomes for neonates and other children with complex surgical needs.

SUMMARY

Over the past decade, significant progress has been made in our ability to measure, benchmark and improve quality in pediatric surgery. Future efforts will need to facilitate broader participation in benchmarking programs and knowledge-sharing collaboratives, and to develop multidisciplinary, 'disease-specific' longitudinal care models where quality measurement extends before and beyond the 'traditional' 30-day perioperative period.

A checklist-based intervention to improve surgical outcomes in Michigan: evaluation of the Keystone Surgery program

IMPORTANCE

Previous studies of checklist-based quality improvement interventions have reported mixed results.

OBJECTIVE

To evaluate whether implementation of a checklist-based quality improvement intervention--Keystone Surgery--was associated with improved outcomes in patients in a large statewide population undergoing general surgery.

DESIGN, SETTING, AND EXPOSURES

A retrospective longitudinal study examined surgical outcomes in 64,891 Michigan patients in 29 hospitals using Michigan Surgical Quality Collaborative clinical registry data from 2006 through 2010. Multivariable logistic regression and difference-in-differences analytic approaches were used to evaluate whether Keystone Surgery program implementation was associated with improved surgical outcomes following general surgery procedures, apart from existing temporal trends toward improved outcomes during the study period.

MAIN OUTCOMES AND MEASURES

Risk-adjusted rates of superficial surgical site infection, wound complication, any complication, and 30-day mortality.

RESULTS

Implementation of Keystone Surgery in 14 participating centers was not associated with improvements in surgical outcomes during the study period. Adjusted rates of superficial surgical site infection (3.2% vs 3.2%, P=.91), wound complication (5.9% vs 6.5%, P=.30), any complication (12.4% vs 13.2%, P=.26), and 30-day mortality (2.1% vs 1.9%, P=.32) at participating hospitals were similar before and after implementation. Difference-in-differences analysis accounting for trends in 15 nonparticipating centers and sensitivity analysis excluding patients receiving surgery in the first 6 or 12 months after program implementation yielded similar results.

CONCLUSIONS AND RELEVANCE

Implementation of a checklist-based quality improvement intervention did not affect rates of adverse surgical outcomes among patients undergoing general surgery in participating Michigan hospitals. Additional research is needed to understand why this program was not successful prior to further dissemination and implementation of this model to other populations.

Surgical debriefing: a reliable roadmap to completing the patient safety cycle

Morbidity and mortality due to preventable medical errors are a disastrous reality in medicine. Debriefing, a process that allows individuals to discuss team performance in a constructive, supportive environment, has been linked to improved performance in various medical and surgical fields, including improvements in specific procedures, teamwork and communication, and error identification. However, the neurosurgical literature on this topic is limited. The authors review the debriefing literature in the field of medicine, with a specific emphasis on the operating room, and they report their own institutional experience with a debriefing module, from invention to pilot implementation, at Vanderbilt University Medical Center. The authors share the challenges and lessons learned from their quality improvement project. The field of neurosurgery would undoubtedly benefit from embracing debriefing, as its potential has been established in other medical specialties and can serve as a valuable role in immediately learning from mistakes. The authors hope that their colleagues can learn from this experience and improve their own.