Communication failures in the operating room: an observational classification of recurrent types and effects

Cognitive Ergonomics: A Review of Interventions for Outpatient Practice

Doctoring is difficult mental work, involving many cognitively demanding processes such as diagnosing, decision-making, parallel processing, communicating, and managing the emotions of others. According to cognitive load theory (CLT), working memory is a limited cognitive resource that can support a finite amount of cognitive load. While the intrinsic cognitive load is the innate load associated with a task, the extraneous load is generated by inefficiency or suboptimal work conditions. Causes of extraneous cognitive load in healthcare include inefficiency, distractions, interruptions, multitasking, stress, poor communication, conflict, and incivility. High levels of cognitive load are associated with impaired function and an increased risk of burnout among physicians. Cognitive ergonomics is the branch of human factors and ergonomics (HFE) focused on supporting the cognitive processes of individuals within a system. In health care, where the cognitive burden on physicians is high, cognitive ergonomics can establish practices and systems that decrease extraneous cognitive load and support pertinent cognitive processes. In this review, we present cognitive ergonomics as a useful framework for conceptualizing an oft-overlooked dimension of labor and apply theory to practice by summarizing evidence-based cognitive ergonomics interventions for outpatient care settings. Our proposed interventions are structured within four general recommendations: 1. minimize distractions, interruptions, and multitasking; 2. optimize the use of the electronic health record (EHR); 3. optimize the use of health information systems (HIS); and 4. support good communication and teamwork. Best practices in cognitive ergonomics can benefit patients, minimize practice inefficiency, and support physician career longevity.

The need for non-technical skills education in orthopedic surgery

BACKGROUND

The issue of surgical safety has increased significantly over the last few decades. Several studies have established that it is linked to non-technical performance, rather than clinical competencies. Non-technical skills can be blended with technical training in the surgical profession to improve surgeons' abilities and enhance patient care and procedural skills. The main goal of this study was to determine orthopedic surgeons' requirements of non-technical skills, and to identify the most pressing issues.

METHODS

We conducted a self-administered online questionnaire survey in this cross-sectional study. The questionnaire was piloted, validated, pretested, and clearly stated the study's purpose. After the pilot, minor wording and questions were clarified before starting the data collection. Orthopedic surgeons from the Middle East and Northern Africa were invited. The questionnaire was based on a five-point Likert scale, the data were analyzed categorically, and variables were summarized as descriptive statistics.

RESULTS

Of the 1713 orthopedic surgeons invited, 60% completed the survey (1033 out of 1713). The majority demonstrated a high likelihood of participating in such activities in the future (80.5%). More than half (53%) of them preferred non-technical skills courses to be part of major orthopedic conferences, rather than independent courses. Most (65%) chose them to be face-to-face. Although 97.2% agreed on the importance of these courses, only 27% had attended similar courses in the last three years. Patient safety, infection prevention and control, and communication skills were ranked at the top as topics to be addressed. Moreover, participants indicated they would most likely attend courses on infection prevention and control, patient safety and teamwork, and team management.

CONCLUSION

The results highlight the need for non-technical skills training in the region and the general preferences regarding modality and setting. These findings support the high demand from orthopedic surgeons' perspective to develop an educational program on non-technical skills.

StOP? II trial: cluster randomized clinical trial to test the implementation of a toolbox for structured communication in the operating room-study protocol

Background

Surgical care, which is performed by intensely interacting multidisciplinary teams of surgeons, anesthetists, and nurses, remains associated with significant morbidity and mortality. Intraoperative communication has been shown to be associated with surgical outcomes, but tools ensuring efficient intraoperative communication are lacking. In a previous study, we developed the StOP?-protocol that fosters structured intraoperative communication. Before the critical phases of the operation, the responsible surgeon initiates and leads one or several StOP?s. During a StOP?, the surgeon informs about the progress of the operation (status), next steps and proximal goals (objectives), and possible problems (problems) and encourages all team members to voice their observations and ask questions (?). In a before-after study performed mainly in visceral surgery, we found effects of the StOP?-protocol on mortality, length of hospital stay, and reoperation. We intend to assess the impact of the StOP?-protocol in a cluster randomized trial, in a wider variety of surgical specialties (i.e., general, visceral, thoracic, vascular surgery, surgical urology, and gynecology). The primary hypothesis is that the consistent use of the StOP?-protocol by the main surgeon reduces patient mortality within 30 days after the operation. The secondary hypothesis is that the consistent use of the StOP?-protocol by the main surgeon reduces unplanned reoperations, length of hospital stay, and unplanned hospital readmissions.

Methods

This study is designed as a multicenter, cluster-randomized parallel-group trial. Board-certified surgeons of participating clinical departments will be randomized 1:1 to the StOP? intervention group or to the standard of care (control) group. The intervention group will undergo a training to use the StOP?-protocol and receive regular feedback on their compliance with the protocol. The surgeons in the control group will communicate as usual during their operations. The unit of observation will be operations performed by cluster surgeons. Consecutive patients will be enrolled over 4 months per cluster. A total of 400 surgeons will be recruited, and we expect to collect patient outcome data for 14,000 surgical procedures.

Discussion

The StOP?-protocol was designed as a tool to structure communication during surgical procedures. Testing its effects on patient outcomes will contribute to implementing evidenced-based interventions to reduce surgical complications.

Trial registration

ClinicalTrials.gov NCT05356962. Registered on May 2, 2022

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06775-y.

Interprofessional differences in preoperative planning—the individualist surgeon

Background

Perioperative processes have a great impact on the quality of surgery. In a high-risk surrounding, proper planning and communication is of upmost importance. We have identified other professions next to surgery with comparable circumstances and conducted a survey to elaborate on the impact of perioperative processes.

Objective

To identify standards in preoperative planning in high-risk professions and determine possible shortcomings in surgical practice.

Methods

Two surveys were constructed and distributed to surgeons, mountain guides, and soldiers. Questions were designed to investigate preoperative planning behavior and compare the different professions.

Results

Nearly every participant (97%) agreed to the fact that preoperative planning helps to avoid complications. Most surgeons agreed that the preoperative and postoperative phase of care had the greatest ability to improve overall quality of care. The opinions about planning were divided. The minority of surgeons agreed to the importance of sharing a plan preoperatively. Soldiers were the profession with the highest rate of plan sharing.

Conclusion

The readiness to communicate varies between professions and is lowest for surgeons. Missing standardization of procedures and the surgeon’s ego might be explanations for this behavior. Interventions to overcome this shortcoming, like the preoperative team timeout, have already been implemented but further improvements are needed.

Addressing the important error of missing surgical items in an operated patient

Background

We aim to analyze the characteristics of incidences of missing surgical items (MSIs) and to examine the changes in MSI events following the implementation of an MSI prevention program.

Methods

All surgical cases registered in our medical center from January 2014 to December 2019 were retrospectively analyzed.

Results

Among 559,910 operations, 154 MSI cases were reported. Mean patient age was 48.67 years (standard deviation, 20.88), and 56.6% were female. The rate of MSIs was 0.259/1000 cases. Seventy-seven MSI cases (53.10%) had no consequences, 47 (32.41%) had mild consequences, and 21 (14.48%) had severe consequences. These last 21 cases represented a rate of 0.037/1000 cases. MSI events were more frequent in cardiac surgery (1.82/1000 operations). Textile elements were the most commonly retained materials (28.97% of cases). In total, 15.86% of the cases were not properly reported. The risk factors associated with MSIs included body mass index (BMI) above 35 kg/m² and prolonged operative time. After the implementation of the institutional prevention system in January 2017, there was a gradual decrease in the occurrence of severe events despite an increase in the number of MSIs.

Conclusion

Despite the increase in the rate of MSIs, an implemented transparency and reporting system helped reduce the cases with serious consequences. To further prevent the occurrence of losing surgical elements in a surgery, we recommend educating OR staff members about responsibility and obligation to report all incidents that are caused during an operation, to develop an event reporting system as well as "rituals" within the OR setting to increase the team's awareness to MSIs.

Trial registration Clinicaltrials.gov (NCT04293536). Date of registration: 08.01.2021. https://clinicaltrials.gov/ct2/show/NCT04293536.

Implementation of An Antibiotic Stewardship Intervention to Reduce Prescription of Fluoroquinolones: A Human Factors Analysis in Two Intensive Care Units

Antibiotic use is often the target of interventions in health care organizations that aim to decrease healthcare-associated infections (HAI) such as Clostridioides difficile (CDI); this is particularly important for fluoroquinolones (FQ), which are frequently used in critical care settings. In this study, using a multiple case study research approach, we conduct an in-depth analysis of an intervention aimed at limiting ICU prescriber access to FQ in two ICUs of two hospitals. The data collection and analysis were guided by a human factors engineering approach based on the SEIPS (Systems Engineering Initiative for Patient Safety) model and evidence-based implementation principles. Our results show some differences in the implementation of the FQ intervention between the two ICUs, such as level and method of FQ restriction, and training and communication with physicians and pharmacists. In both ICUs, several organizational learning mechanisms helped to quickly identify problems with the intervention and ensure that changes were made in a just-in-time manner (e.g. just-in-time training, removal of FQ in order set for pneumonia). Despite their organizational differences, both sites developed strategies to successfully implement the FQ intervention.

Latent Safety Threats and Countermeasures in the Operating Theater: A National In Situ Simulation-Based Observational Study

INTRODUCTION

In situ simulation provides a valuable opportunity to identify latent safety threats (LSTs) in real clinical environments. Using a national simulation program, we explored latent safety threats (LSTs) identified during in situ multidisciplinary simulation-based training in operating theaters in hospitals across New Zealand.

METHOD

Surgical simulations lasting between 15 and 45 minutes each were run as part of a team training course delivered in 21 hospitals in New Zealand. After surgical in situ simulations, instructors used a template to record identified LSTs in a postcourse report. We analyzed these reports using the contributory factors framework from the London Protocol to categorize LSTs.

RESULTS

Of 103 postcourse reports across 21 hospitals, 77 contained LSTs ranging across all factors in the London Protocol. Common threats included staff knowledge and skills in emergencies, team factors, factors related to task or technology, and work environment threats. Team factors were also commonly reported as protecting against adverse events, in particular, creating a shared mental model. Examples of actions taken to address threats included replacing or repairing faulty equipment, clarifying emergency processes, correcting written information, and staff training for clinical emergencies.

CONCLUSIONS

The pervasiveness of LSTs suggests that our results have widespread relevance to surgical departments throughout New Zealand and elsewhere and that collective solutions would be valuable. In situ simulation is an effective mechanism both for identifying threats to patient safety and to prompt initiatives for improvement, supporting the use of in situ simulation in the quality improvement cycle in healthcare.

The Effect of Educational Intervention on the Improvement of Nontechnical Skills in Circulating Nurses

Background

Nontechnical skills are necessary for clinicians' safe performance and prevention of errors in the operating room. Educational intervention is a useful way to improve these skills, which are a vital area for improvement. Circulating nurses are surgical team members whose work depends heavily on using nontechnical skills. This study is aimed at assessing the effect of an educational intervention on the improvement of circulating nurses' nontechnical skills.

Methods

This semiexperimental study was conducted on 300 circulating nurses divided into the intervention and no intervention groups each containing 150 participants. The nontechnical skills were assessed using the circulating practitioners' list of nontechnical skills. Then, the intervention group received training regarding these skills, and the two groups were evaluated again. After all, the data were entered into the SPSS 24 software and were analyzed using descriptive statistics and Wilcoxon and Mann–Whitney tests. Furthermore, Kendall's tau, independent sample t-test, and one-way ANOVA were used for assessment of relationship between median scores and demographics.

Results

The results revealed a significant improvement in the scores of all domains of nontechnical skills in the intervention group (p < 0.05). The highest and lowest improvements were observed in teamwork (42%) and situational awareness (16.7%), respectively. After the intervention, the scores of some of the behaviors were still below the average level or were not improved significantly.

Conclusions

Circulating nurses' nontechnical skills can be improved by educational interventions. However, regarding the low scores or no improvements in the scores of some behaviors, other intervention types such as policymaking and correcting the existing hierarchies in the operating room can be useful to complete the educational interventions.

The surgical safety checklist: a quantitative study on attitudes and barriers among gynecological surgery teams

Background

Implementation of the surgical safety checklist (SSC) plays a significant role in improving surgical patient safety, but levels of compliance to a SSC implementation by surgical team members vary significantly. We aimed to investigate the factors affecting satisfaction levels of gynecologists, anesthesiologists, and operating room registered nurses (OR-RNs) with SSC implementation.

Methods

We conducted a survey based on 267 questionnaires completed by 85 gynecologists from 14 gynecological surgery teams, 86 anesthesiologists, and 96 OR-RNs at a hospital in China from March 3 to March 16, 2020. The self-reported questionnaire was used to collect respondent’s demographic information, levels of satisfaction with overall implementation of the SSC and its implementation in each of the three phases of a surgery, namely sign-in, time-out, and sign-out, and reasons for not giving a satisfaction score of 10 to its implementation in all phases.

Results

The subjective ratings regarding the overall implementation of the SSC between the surgical team members were different significantly. “Too many operations to check” was the primary factor causing gynecologists and anesthesiologists not to assign a score of 10 to sign-in implementation. The OR-RNs gave the lowest score to time-out implementation and 82 (85.42%) did not assign a score of 10 to it. “Surgeon is eager to start for surgery” was recognized as a major factor ranking first by OR-RNs and ranking second by anesthesiologists, and 57 (69.51%) OR-RNs chose “Too many operations to check” as the reason for not giving a score of 10 to time-out implementation. “No one initiates” and “Surgeon is not present for ‘sign out’” were commonly cited as the reasons for not assigning a score of 10 to sign-out implementation.

Conclusion

Factors affecting satisfaction with SSC implementation were various. These factors might be essentially related to heavy workloads and lack of ability about SSC implementation. It is advisable to reduce surgical team members’ excessive workloads and enhance their understanding of importance of SSC implementation, thereby improving surgical team members’ satisfaction with SSC implementation and facilitating compliance of SSC completion.

The TEAM instrument for measuring emergency team performance: validation of the Swedish version at two emergency departments

BACKGROUND

The Team Emergency Assessment Measure (TEAM) questionnaire is designed for rating the non-technical performance of emergency medical teams during emergencies, e.g., resuscitation or trauma management. Originally developed in Australia it has today been translated and validated into eleven languages, but a Swedish version is lacking. The aim was therefore to cross-culturally translate and evaluate the reliability and validity of the TEAM questionnaire in a Swedish health care setting.

METHODS

The instrument was forward and backward translated and adapted into a Swedish context according to established guidelines for cross-cultural adaptation of survey-based measures. The translated version was tested through 78 pairwise assessments of 39 high-priority codes at the emergency departments of two major hospitals. The raters observed the teams at work in real time and filled in the questionnaires immediately afterwards independently of each other. Psychometric properties of the instrument were evaluated.

RESULTS

The original instrument was translated by pairs of translators independently of each other and reviewed by an expert committee of researchers, nurses and physicians from different specialties, a linguist and one of the original developers of the tool. A few adaptations were needed for the Swedish context. A principal component factor analysis confirmed a single 'teamwork' construct in line with the original instrument. The Swedish version showed excellent reliability with a Cronbach's alpha of 0.955 and a mean inter-item correlation of 0.691. The mean item-scale correlation of 0.82 indicated high internal consistency reliability. Inter-rater reliability was measured by intraclass correlation and was 0.74 for the global score indicating good reliability. Individual items ranged between 0.52 and 0.88. No floor effects but ceiling effects were noted. Finally, teams displaying clear closed-loop communication had higher TEAM scores than teams with less clear communication.

CONCLUSIONS

Real time observations of authentic, high priority cases at two emergency departments show that the Swedish version of the TEAM instrument has good psychometric properties for evaluating team performance. The TEAM instrument is thus a welcome tool for assessing non-technical skills of emergency medical teams.

Barriers and facilitators to interdisciplinary communication during consultations: a qualitative study

OBJECTIVE

Communication failures between clinicians lead to poor patient outcomes. Critically injured patients have multiple injured organ systems and require complex multidisciplinary care from a wide range of healthcare professionals and communication failures are abundantly common. This study sought to determine barriers and facilitators to interdisciplinary communication between the consulting trauma, intensive care unit (ICU) team and specialty consultants for critically injured patients at an urban, safety-net, level 1 trauma centre.

DESIGN

An observational qualitative study of barriers and facilitators to interdisciplinary communication.

SETTING

We conducted observations of daily rounds in two trauma surgical ICUs and recorded the most frequently consulted teams.

PARTICIPANTS

Key informant interviews after presenting clinical vignettes as discussion prompts were conducted with a broad range of clinicians from the ICUs and physicians and nurse practitioners from the consultant teams who were identified during the observations. Interviews were recorded and transcribed verbatim. Data of these 10 interviews were combined with primary transcript data from prior study (25 interviews) and analysed together because of the same setting with same themes. Independent coding of the transcripts, with iterative reconciliation, was performed by two coders.

OUTCOMES MEASURES

Facilitators and barriers of interdisciplinary communication were identified.

RESULTS

A total of 35 interview transcripts were analysed. Cardiology and interventional radiology were the most frequently consulted teams. Consulting and consultant clinicians reported that perceived accessibility from the team seeking a consultation and the consultant team impacted interdisciplinary communication. Accessibility had a physical dimension as well as a psychological dimension. Accessibility was demonstrated by responsiveness between clinicians of different disciplines and in turn facilitated interdisciplinary communication. Social norms, cognitive biases, hierarchy and relationships were reported as both facilitators and barriers to accessibility, and therefore, interdisciplinary communication.

CONCLUSION

Accessibility impacted interdisciplinary communication between the consulting and the consultant team.

ARTICLE SUMMARY

Elucidates barriers and facilitators to interdisciplinary communication between consulting and consultant teams.

The impact of a structured handover checklist for intraoperative staff shift changes on effective communication, OR team satisfaction, and patient safety: a pilot study

Objective

Handover without a structured format is prone to the omission of information and could be a potential risk to patient safety. We sought to determine the effect of a structured checklist on the quality of intraoperative change of shift handover between scrubs and circulars.

Methods

We conducted a control intervention study on operating room wards of two teaching hospitals from 20 Feb to 21 Nov 2020. This research was conducted in three stages as follows: assessing the current situation (as a group before the intervention), performing the intervention and evaluating the effect of using a checklist on handover quality after the intervention in two groups: with and without checklist. We examined the quality of handover between scrub and circular personnel in terms of handover duration and quality, omission of information and improvement in OR staff satisfaction.

Results

A total of 120 handovers were observed and evaluated. After intervention in the group using the checklist, the percentage of information omission in surgical report was decreased from 19.5 to 12.1% between scrubs (P < 0.00) and from 16.8 to 14.1% between circulars (P < 0.03). Also, in the role of scrub, the mean overall score of handover process quality was significantly higher after the intervention (x̄ = 7 ± 1.5) than before it (x̄ = 6.5 ± 0.9) (p < 0.02). In the role of circulating, despite the positive effect of overall score checklist, no significant difference was observed (p < 0.08). The use of checklist significantly increased the handover duration between scrubs (p < 0.03) and circulars (p < 0.00). The overall mean percentage of handover satisfaction increased from 67.5% before the intervention to 85.5% after the intervention (p < 0.00).

Conclusion

The implementation of a new structured handover checklist had a positive impact on improving the quality of communication between the surgical team, reducing the information omission rate and increasing the satisfaction.

Different roles with different goals: Designing to support shared situational awareness between patients and clinicians in the hospital

Objective

Team situational awareness helps to ensure high-quality care and prevent errors in the complex hospital environment. Although extensive work has examined factors that contribute to breakdowns in situational awareness among clinicians, patients’ and caregivers’ roles have been neglected. To address this gap, we studied team-based situational awareness from the perspective of patients and their caregivers.

Materials and Methods

We utilized a mixed-methods approach, including card sorting and semi-structured interviews with hospitalized patients and their caregivers at a pediatric hospital and an adult hospital. We analyzed the results utilizing the situational awareness (SA) theoretical framework, which identifies 3 distinct stages: (1) perception of a signal, (2) comprehension of what the signal means, and (3) projection of what will happen as a result of the signal.

Results

A total of 28 patients and 19 caregivers across the 2 sites participated in the study. Our analysis uncovered how team SA helps patients and caregivers ensure that their values are heard, their autonomy is supported, and their clinical outcomes are the best possible. In addition, our participants described both barriers—such as challenges with communication—and enablers to facilitating shared SA in the hospital.

Discussion

Patients and caregivers possess critical knowledge, expertise, and values required to ensure successful and accurate team SA. Therefore, hospitals need to incorporate tools that facilitate patients and caregivers as key team members for effective SA.

Conclusions

Elevating patients and caregivers from passive recipients to equal contributors and members of the healthcare team will improve SA and ensure the best possible outcomes.

Perspectives on team communication challenges in caring for children with medical complexity

BACKGROUND

Children with medical complexity (CMC) require the expertise of many care providers spanning different disciplines, institutions, and settings of care. This leads to duplicate health records, breakdowns in communication, and limited opportunities to provide comprehensive, collaborative care. The objectives of this study were to explore communication challenges and solutions/recommendations from multiple perspectives including (i) parents, (ii) HCPs - hospital and community providers, and (iii) teachers of CMC with a goal of informing patient care.

METHODS

This qualitative study utilized an interpretive description methodology. In-depth semi-structured interviews were conducted with parents and care team members of CMC. The interview guides targeted questions surrounding communication, coordination, access to information and roles in the health system. Interviews were conducted until thematic saturation was reached. Interviews were audio-recorded, transcribed verbatim, and coded and analyzed using thematic analysis.

RESULTS

Thirty-two individual interviews were conducted involving parents (n = 16) and care team members (n = 16). Interviews revealed 2 main themes and several associated subthemes (in parentheses): (1) Communication challenges in the care of CMC (organizational policy and technology systems barriers, inadequate access to health information, and lack of partnership in care) (2) Communication solutions (shared systems that can be accessed in real-time, universal access to health information, and partnered contribution to care).

CONCLUSION

Parents, HCPs, and teachers face multiple barriers to communication and information accessibility in their efforts to care for CMC. Parents and care providers in this study suggested potential strategies to improve communication including facilitating communication in real-time, universal access to health information and meaningful partnerships.

Checklist feasibility and impact in gastrointestinal endoscopy: a systematic review and narrative synthesis

Background and study aim  Checklists prevent errors and have a positive impact on patient morbidity and mortality in surgical settings. Despite increasing use of checklists in gastrointestinal endoscopy units across many countries, a summary of cumulated experience is lacking. The aim of this study was to identify and evaluate the feasibility of successful checklist implementation in gastrointestinal endoscopy units and summarise the evidence of its impact on the commitment in safety culture. Methods  A comprehensive literature search was performed identifying the use of a checklist or time-out in endoscopy units from 1978 to January 2020 using OVID MEDLINE, EMBASE, and ISI Web of Knowledge databases, with search terms related to checklist and endoscopy. We summarised overall adherence to checklists from included studies through a narrative synthesis, characterizing barriers and facilitators according to nurse and physician perspectives, while also summarizing safety endpoints. Results  The seven studies selected from 673 screened citations were highly heterogeneous in terms of methodology, context, and outcomes. Across five of these, checklist adherence rates post-intervention varied for both nurses (84 % to 96 %) and physicians (66 % to 95 %). Various facilitators (education, continued reassessment) and barriers (lack of safety culture, checklist completion time) were identified. Most studies did not report associations between checklist implementation and clinical outcomes, except for better team communication. Conclusion  Implementation of a gastrointestinal endoscopy checklist is feasible, with an understanding of relevant barriers and facilitators. Apart from a significant increase in the perception of team communication, evidence for a measurable impact attributable to gastrointestinal checklist implementation on endoscopic processes and safety outcomes is limited and warrants further study.

Communication as a non-technical skill in the operating room: A qualitative study

Aim

The aim of this study was to explore how operating room nurses (ORNs) experience operating room (OR) team communication concerning non‐technical skills.

Design

Based on the Scrub Practitioners List of Intraoperative Non‐Technical Skill (SPLINTS), qualitative individual in‐depth semi‐structured interviews were conducted with 11 ORNs in a Norwegian university hospital. Braun and Clarke's six analytic phases for thematic data analysis were used.

Results

Surgeons being unprepared or demanding different instruments than the preoperative information indicates, cause stress and frustration. So does noise and brusquely or poor communication. Ensuring good information flow within the entire team is important. When silence is required, the ORNs communicate with gestures, looks and nods. Creating a positive and secure team culture facilitates discussions, questions and information sharing.

Conclusion

Inappropriate dynamics, inaccurate and/or disrespectful communication and noise may reduce patient safety. Interdisciplinary team training may bring attention to the value of communication as a non‐technical skill.

OR and ICU teams 'running in parallel' at the end of cardiothoracic surgery improves perceptions of handoff safety

The transfer of a cardiac surgery patient from the operating room (OR) to the intensive care unit (ICU) is both a challenging process and a critical period for outcomes. Information transferred between these two teams-known as the 'handoff'-has been a focus of efforts to improve patient safety. At our institution, staff have poor perceptions of handoff safety, as measured by low positive response rates to questions found in the Agency for Health Care Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (HSOPS). In this quality improvement project, we developed a novel handoff protocol after cardiac surgery where we invited the ICU nurse and intensivist into the OR to receive a face-to-face handoff from the circulating nurse, observe the final 30 min of the case, and participate in the end-of-case debrief discussions. Our aim was to increase the positive response rates to handoff safety questions to meet or surpass the reported AHRQ national averages. We used plan, do, study, act cycles over the course of 123 surgical cases to test how our handoff protocol was leading to changes in perceptions of safety. After a 10-month period, we achieved our aim for four out of the five HSOPS questions assessing safety of handoff. Our results suggest that having an ICU team 'run in parallel' with the cardiac surgical team positively impacts safety culture.

Association Between Implementing Comprehensive Learning Collaborative Strategies in a Statewide Collaborative and Changes in Hospital Safety Culture

Importance

Hospital safety culture remains a critical consideration when seeking to reduce medical errors and improve quality of care. Little is known regarding whether participation in a comprehensive, multicomponent, statewide quality collaborative is associated with changes in hospital safety culture.

Objective

To examine whether implementation of a comprehensive, multicomponent, statewide surgical quality improvement collaborative is associated with changes in hospital safety culture.

Design, Setting, and Participants

In this survey study, the Safety Attitudes Questionnaire, a 56-item validated survey covering 6 culture domains (teamwork, safety, operating room safety, working conditions, perceptions of management, and employee engagement), was administered to a random sample of physicians, nurses, operating room staff, administrators, and leaders across Illinois hospitals to assess hospital safety culture prior to launching a new statewide quality collaborative in 2015 and then again in 2017. The final analysis included 1024 respondents from 36 diverse hospitals, including major academic, community, and rural centers, enrolled in ISQIC (Illinois Surgical Quality Improvement Collaborative).

Exposures

Participation in a comprehensive, multicomponent statewide surgical quality improvement collaborative. Key components included enrollment in a common standardized data registry, formal quality and process improvement training, participation in collaborative-wide quality improvement projects, funding support for local projects, and guidance provided by surgeon mentors and process improvement coaches.

Main Outcomes and Measures

Perception of hospital safety culture.

Results

The overall survey response rate was 43.0% (580 of 1350 surveys) in 2015 and 39.0% (444 of 1138 surveys) in 2017 from 36 hospitals. Improvement occurred in all the overall domains, with significant improvement in teamwork climate (change, 3.9%; P = .03) and safety climate (change, 3.2%; P = .02). The largest improvements occurred in individual measures within domains, including physician-nurse collaboration (change, 7.2%; P = .004), reporting of concerns (change, 4.7%; P = .009), and reduction in communication breakdowns (change, 8.4%; P = .005). Hospitals with the lowest baseline safety culture experienced the largest improvements following collaborative implementation (change range, 11.1%-14.9% per domain; P < .05 for all). Although several hospitals experienced improvement in safety culture in 1 domain, most hospitals experienced improvement across several domains.

Conclusions and Relevance

This survey study found that hospital enrollment in a statewide quality improvement collaborative was associated with overall improvement in safety culture after implementing multiple learning collaborative strategies. Hospitals with the poorest baseline culture reported the greatest improvement following implementation of the collaborative.

The Swedish version of the TeamSTEPPS® teamwork attitudes questionnaire (T-TAQ): A validation study

Background

Effective teamwork is essential for delivering safe health care. It is important to increase patient safety in healthcare by conducting interprofessional team training with both healthcare professionals and undergraduate students. Validated questionnaires that evaluate team training activities contribute to valuable knowledge regarding changes in attitudes toward teamwork. The aim of the study was to test the reliability and structural validity of the Swedish version of the TeamSTEPPS® Teamwork Attitudes Questionnaire (T-TAQ).

Methods

The study had a cross-sectional design. Four hospitals in three health care regions in Sweden participated in the study. In total, 458 healthcare professionals, response rate 39.4%, completed the questionnaire. The T-TAQ, which consists of 30 items and covers five dimensions (Team Structure, Leadership, Situation Monitoring, Mutual Support and Communication), was translated to Swedish. A paper version of the T-TAQ was distributed to healthcare professionals (physicians, registered nurses, midwives, nursing assistants and allied health professionals) from the hospitals. Reliability and validity were tested using Cronbach’s alpha and confirmatory factor analysis.

Results

Cronbach’s alpha was 0.70 for the total T-TAQ and ranged from 0.41 to 0.87 for the individual dimensions. The goodness-of-fit indexes in the confirmatory factor analysis (Model 2) revealed a normed chi-square of 2.96, a root mean square error of approximation of 0.068, a Tucker-Lewis index of 0.785 and a comparative fit index of 0.808.

Conclusions

The Swedish version of the T-TAQ has some potential to measure healthcare professionals’ general attitudes toward the core components of teamwork in hospital settings. Further validation studies of the Swedish version of the T-TAQ are required, with samples representing both healthcare professionals and students from various healthcare disciplines and educational levels.

[Competence and communication in the implementation of computer-assisted surgical planning]

In the past the planning of surgical interventions in oral and maxillofacial surgery was based on the clinical picture with the assistance of conventional 2‑dimensional X‑ray images. In cases in which the occlusion was affected, plaster cast models of the jaws were included as a planning aid. With introduction of computed tomography (CT) and the possibility to obtain a 3-dimensional picture of bony structures, it was possible for the first time to construct a virtual image of bony structures and therefore of traumatic, iatrogenic and congenital deformities. Using stereolithographic models, these 3‑dimensional relationships were easily "understandable". Risks could be better classified in the planning of an operative intervention and these models could be used as a basis for communication. It was also possible to use the data acquired by CT for design and construction of so-called CAD/CAM patient-specific implants and to implant them; however, the resolution of the data sets and thus the level of detail did not yet correspond to the current standard, so that "delicate" structures could not be constructed. With the improvement of the resolution of CT and the possibility of additive construction processes, such as the selective laser melting (SLM) process or the 3D printing process, the improvement of precision and shaping of the implant practically without limits became reality. Through the bundling of competencies on both sides, engineer and physician, complex computer-aided planning has now become possible. The basis for this is precise communication to avoid errors in the planning process, which in particular needs individual patient information, e.g. about the structure and quality of the overlying soft tissues.

Quality Improvement Project of a Massive Transfusion Protocol (MTP) to Reduce Wastage of Blood Components

Massive transfusion protocols (MTPs) facilitate the organized delivery of blood components for traumatically injured patients. MTPs vary across institutions, and ratios of blood components can change during clinical management. As a result, significant amounts of components can be wasted. We completed a review of all MTP activations from 2015 to 2018, providing an in-depth analysis of waste in our single Level 1 trauma center. An interdepartmental group analyzed patterns of blood component wastage to guide three quality improvement initiatives. Specifically, we (1) completed a digital timeline for each MTP activation and termination, (2) improved communications between departments, and (3) provided yearly training for all personnel about MTP deployment. The analysis identified an association between delayed MTP deactivations and waste (RR = 1.48, CI 1.19–1.85, p = 0.0005). An overall improvement in waste was seen over the years, but this could not be attributed to increased closed-loop communication as determined by the proportion of non-stop activations (F(124,3) = 0.98, not significant). Delayed MTP deactivations are the primary determinant of blood component waste. Our proactive intervention on communications between groups was not sufficient in reducing the number of delayed deactivations. However, implementing a digital timeline and regular repetitive training yielded a significant reduction in wasted blood components.

Bundle interventions including nontechnical skills for surgeons can reduce operative time and improve patient safety

OBJECTIVE

This study aimed to determine if introducing nontechnical skills to surgical trainees during surgical education can reduce the operation time and contribute to patient safety.

DESIGN

Quality improvement initiatives using the KAIZEN as a problem-solving method.

SETTING

Department of surgery in a referral and educational hospital.

PARTICIPANTS

Surgical team and quality management team.

INTERVENTION

The KAIZEN was used as a problem-solving method between 2015 and 2018 to reduce the operation time. First, baseline measurement was performed to understand the current situations in our department. To achieve continuous improvement, periodical feedback of the current status was obtained from all staff. Bundles, including nontechnical skills, were established. Briefing and debriefing were performed by the surgical team.

MAIN OUTCOME MEASURES

Excessively long operation rates with a standard procedure.

RESULTS

We included 1573 operations in this initiative. Excessively long operation rates were reduced in all types of surgeries, from 27.1% to 15.2% for herniorrhaphy (P = 0.005), 58.3-40.0% for gastrectomy (P = 0.03), 50.0-4.1% for total gastrectomy (P = 0.12), 65.6-45.0% for colectomy (P = 0.004), 67.8-43.2% for high anterior resection (P = 0.02) and 69.6-47.9% for low anterior resection (P = 0.03). The adherence to briefing and debriefing were improved, and majority of the surgeons favored the bundle elements.

CONCLUSIONS

The KAIZEN initiative was effective in clinical healthcare settings. In the event of scaling-up this initiative, the educational program for physicians should include project management strategies and leadership skills.

You Have Control: aviation communication application for safety-critical times in surgery

High-risk organisations (HRO), including aviation, undergo formal communication training, with emphasis on safety-critical moments. Such training is not widespread or mandatory in healthcare, and while there are many differences both share the 'human element' with circumstances leading to an increased risk of harm. A typical operating theatre consists of an operating surgeon, and an assisting surgeon, roles that may change throughout the course of a procedure. Similarly, a training aircraft or multi-crew cockpit (flight deck) has a pilot in control, or 'pilot flying', and a 'pilot not flying'. Both interact with wider teams, for example the scrub team and air traffic controllers, respectively. Surgical error is the second most prevalent cause of preventable harm to patients after drug errors. Every year in the UK National Health Service (NHS), there are typically 500 never events, 21,000 serious incidents, and many more episodes of physical or psychological harm. Ineffective communication (46%) is the most common behavioural factor leading to a never event. In this review, we examine the concept of 'sterile cockpit', use of unambiguous terminology, callsigns, important information readback, sharing of mental models, and the mini-brief, and how these may be used to reduce patient harm during safety-critical moments.

Examining the impact of an asynchronous communication platform versus existing communication methods: an observational study

Background

Healthcare systems revolve around intricate relations between humans and technology. System efficiency depends on information exchange that occur on synchronous and asynchronous platforms. Traditional synchronous methods of communication may pose risks to workflow integrity and contribute to inefficient service delivery and medical care.

Aim

To compare synchronous methods of communication to Medic Bleep, an instant messaging asynchronous platform, and observe its impact on clinical workflow, quality of work life and associations with patient safety outcomes and hospital core operations.

Methods

Cohorts of healthcare professionals were followed using the Time Motion Study methodology over a 2-week period, using both the asynchronous platform and the synchronous methods like the non-cardiac pager. Questionnaires and interviews were conducted to identify staff attitudes towards both platforms.

Results

A statistically significant figure (p<0.01) of 20.1 minutes’ reduction in average task completion was seen with asynchronous communication, saving 58.8% of time when compared with traditional synchronous methods. In subcategory analysis for staff: doctors, nurses and midwifery categories, a p value of <0.0495 and <0.01 were observed; a mean time reduction with statistical significance was also seen in specific task efficiencies of ‘To-Take-Out (TTO), patient review, discharge & patient transfer and escalation of care & procedure’. The platform was favoured with an average Likert value of 8.7; 67% found it easy to implement.

Conclusion

The asynchronous platform improved clinical communication compared with synchronous methods, contributing to efficiencies in workflow and may positively affect patient care.

Role of requests and communication breakdowns in the coordination of teamwork: a video-based observational study of hybrid operating rooms

OBJECTIVES

This study investigated the functional role of 'requests' in the coordination of surgical activities in the operating room (OR). A secondary aim was to describe, closely, instances of potential miscommunication to scrutinise how so-called conversational repairs were used to address and prevent mistakes.

DESIGN

Non-participant video-based observations.

SETTING

Team coordination around image acquisitions (digital subtraction angiography) done during endovascular aortic repair (EVAR) procedures in a hybrid OR.

METHODS

The study followed and documented a total of 72 EVAR procedures, out of which 12 were video-recorded (58 hours). The results were based on 12 teams operating during these recorded surgeries and specifically targeted all sequences involving controlled apnoea. In total, 115 sequences were analysed within the theoretical framework of conversation analysis.

RESULTS

The results indicated a simple structure of communication that can enable the successful coordination of work between different team members. Central to this analysis was the distinction between immediate requests and pre-requests. The results also showed how conversational repairs became key in establishing joint understanding and, therefore, how they can function as crucial resources in safety management operations.

CONCLUSION

The results suggest the possibility of devising an interactional framework to minimise problems with communication, thereby enabling the advancement of patient safety. By making the distinction between different types of requests explicit, certain ambiguities can be mitigated and some misunderstandings avoided. One way to accomplish this practically would be to tie various actions to clearer and more distinct forms of expression.

What attributes define excellence in a trauma team? A qualitative study

Background

Hospital trauma teams consist of a diverse spectrum of health care professionals who work together to deliver quality care. Although the qualities of a well-performing trauma team are often believed to be self-evident, there is little objective information about the most desirable personal and professional characteristics associated with quality trauma care. The aim of this study was to determine the traits and characteristics deemed of greatest value for a trauma team leader and a trauma team member in the adult trauma care setting.

Methods

Semistructured interviews were conducted with trauma team leaders and trauma team members at a tertiary Canadian trauma centre. Standard qualitative research methodology was used. Interviews were recorded, transcribed and analyzed via an inductive analysis approach.

Results

Thematic saturation was achieved after 5 interviews, and 6 further interviews were conducted to ensure that a breadth of trauma care disciplines were included. Six attributes were identified to be of greatest value for trauma team leaders: communication, role clarity, experience, anticipation, management and decisiveness. Four attributes were identified to be of greatest value for trauma team members: engagement, efficiency, experience and collaboration. We further characterized the language defining the ranking of performance for each of these attributes.

Conclusion

Results of this qualitative study involving an experienced and diverse spectrum of trauma team practitioners provide insight into the characteristics that are critical to establishing a “good” trauma team. These findings can be used to inform future determinations of the quality of trauma teams, the education of trauma practitioners and continuing medical education training and assessment tools.

Impact of the "Mind the risk" Campaign of Sociedade Brasileira de Ortopedia e Traumatologia on Risk Perception and Use of the Surgical Checklist by Brazilian Orthopedists

Objective  To analyze the impact of the educational actions included in the "Mind the Risk" campaign of Sociedade Brasileira de Traumatologia e Ortopedia (Brazilian Society of Traumatology and Orthopedics, SBOT, in Portuguese), to increase the perception of the risk involved in the surgical activity and the use of the surgical checklist. Methods  A comparative research was performed during the 50th Brazilian Congress on Orthopedics and Traumatology (50° CBOT, in Portuguese) in November 2018, using a questionnaire similar to the one used in previous two versions. Results  The number of participants was 730, corresponding to 18,7% of the total of 3,903 enrolled in the 50° CBOT. Among the participants, 542 orthopedists (74,2%) reported having experienced errors within the surgical units and 218 (29,8%) surgeries in wrong sites. In total, 624 participants (85,5%) reported marking the surgical site and 402 (55%) using the surgical checklist systematically. Conclusion  In the sample studied, it was evidenced that SBOT's efforts to disseminate the World Health Organization (WHO) protocol were effective, reducing the number of orthopedists who were unaware of it from 65.3% (in 2012) to 20.7% (in 2018), and expanding its use. In 2018, 402 participants (55%) reported the systematic use of the protocol, compared with 301 (40,8%) in 2014. These data confirm the need for educational campaigns and systematic training, not only to promote behavioral change, but especially a cultural change.

A qualitative study of how inter-professional teamwork influences perioperative nursing

Aim

To explore Norwegian operating room nurses' perceptions of how team skills in the inter-professional operating room team influence perioperative nursing in relation to patient safety.

Design

A qualitative, descriptive study based on interviews.

Methods

Ten operating room nurses (N = 10) employed in four Norwegian hospitals were interviewed individually. A qualitative inductive content analysis was conducted. The study was reported adhering to the Consolidated Criteria for Reporting Qualitative Research Checklist.

Results

Three generic categories, containing three subcategories each, were identified illuminate the operating room nurses' perceptions. The operating room team's team skills influence on (a) the quality of perioperative nursing, about task performance, result for the patient and learning; (b) the progress of perioperative nursing, by keeping focus on the task, being prepared and task distribution and (c) the operating room nurses' work environment in the operating room, including confidence, stress and energy use and irritation or job satisfaction.

Evaluation of the effect of multidisciplinary simulation-based team training on patients, staff and organisations: protocol for a stepped-wedge cluster-mixed methods study of a national, insurer-funded initiative for surgical teams in New Zealand public hospitals

INTRODUCTION

NetworkZ is a national, insurer-funded multidisciplinary simulation-based team-training programme for all New Zealand surgical teams. NetworkZ is delivered in situ, using full-body commercial simulators integrated with bespoke surgical models. Rolled out nationally over 4 years, the programme builds local capacity through instructor training and provision of simulation resources. We aim to improve surgical patient outcomes by improving teamwork through regular simulation-based multidisciplinary training in all New Zealand hospitals.

METHODS AND ANALYSIS

Our primary hypothesis is that surgical patient outcomes will improve following NetworkZ. Our secondary hypotheses are that teamwork processes will improve, and treatment injury claims will decline. In addition, we will explore factors that influence implementation and sustainability of NetworkZ and identify organisational changes following its introduction. The study uses a stepped-wedge cluster design. The intervention will roll out at yearly intervals to four cohorts of five District Health Boards. Allocation to cohort was purposive for year 1, and subsequently randomised. The primary outcome measure is Days Alive and Out of Hospital at 90 days using patient data from an existing national administrative database. Secondary outcomes measures will include analysis of postoperative complications and treatment injury claims, surveys of teamwork and safety culture, in-theatre observations and stakeholder interviews.

ETHICS AND DISSEMINATION

We believe this is the first surgical team training intervention to be implemented on a national scale, and a unique opportunity to evaluate a nation-wide team-training intervention for healthcare teams. By using a pre-existing large administrative data set, we have the potential to demonstrate a difference to surgical patient outcomes. This will be of interest to those working in the field of healthcare teamwork, quality improvement and patient safety. New Zealand Health and Disability Ethic Committee approval (#16/NTB/143).

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trials Registry ID ACTRN12617000017325 and the Universal Trial Number is U1111-1189-3992.

Is there a need for formal undergraduate patient handover training and could an educational workshop effectively provide this? A proof-of-concept study in a Scottish Medical School

BACKGROUND

Poor communication between healthcare professionals is recognised as accounting for a significant proportion of adverse patient outcomes. In the UK, the General Medical Council emphasises effective handover (handoff) as an essential outcome for medical graduates. Despite this, a significant proportion of medical schools do not teach the skill.

OBJECTIVES

This study had two aims: (1) demonstrate a need for formal handover training through assessing the pre-existing knowledge, skills and attitudes of medical students and (2) study the effectiveness of a pilot educational handover workshop on improving confidence and competence in structured handover skills.

DESIGN

Students underwent an Objective Structured Clinical Examination style handover competency assessment before and after attending a handover workshop underpinned by educational theory. Participants also completed questionnaires before and after the workshop. The tool used to measure competency was developed through a modified Delphi process.

SETTING

Medical education departments within National Health Service (NHS) Lanarkshire hospitals.

PARTICIPANTS

Forty-two undergraduate medical students rotating through their medical and surgical placements within NHS Lanarkshire enrolled in the study. Forty-one students completed all aspects.

MAIN OUTCOME MEASURES

Paired questionnaires, preworkshop and postworkshop, ascertained prior teaching and confidence in handover skills. The questionnaires also elicited the student's views on the importance of handover and the potential effects on patient safety. The assessment tool measured competency over 12 domains.

RESULTS

Eighty-three per cent of participants reported no previous handover teaching. There was a significant improvement, p<0.0001, in confidence in delivering handovers after attending the workshop. Student performance in the handover competency assessment showed a significant improvement (p<0.05) in 10 out of the 12 measured handover competency domains.

CONCLUSIONS

A simple, robust and reproducible intervention, underpinned by medical education theory, can significantly improve competence and confidence in medical handover. Further research is required to assess long-term outcomes as student's transition from undergraduate to postgraduate training.

The impact of a wireless audio system on communication in robotic-assisted laparoscopic surgery: A prospective controlled trial

Background

Robotic surgery presents a challenge to effective teamwork and communication in the operating theatre (OR). Our objective was to evaluate the effect of using a wireless audio headset device on communication, efficiency and patient outcome in robotic surgery.

Methods and findings

A prospective controlled trial of team members participating in gynecologic and urologic robotic procedures between January and March 2015. In the first phase, all surgeries were performed without headsets (control), followed by the intervention phase where all team members used the wireless headsets. Noise levels were measured during both phases. After each case, all team members evaluated the quality of communication, performance, teamwork and mental load using a validated 14-point questionnaire graded on a 1–10 scale. Higher overall scores indicated better communication and efficiency. Clinical and surgical data of all patients in the study were retrieved, analyzed and correlated with the survey results. The study included 137 procedures, yielding 843 questionnaires with an overall response rate of 89% (843/943). Self-reported communication quality was better in cases where headsets were used (113.0 ± 1.6 vs. 101.4 ± 1.6; p < .001). Use of headsets reduced the percentage of time with a noise level above 70 dB at the console (8.2% ± 0.6 vs. 5.3% ± 0.6, p < .001), but had no significant effect on length of surgery nor postoperative complications.

Conclusions

The use of wireless headset devices improved quality of communication between team members and reduced the peak noise level in the robotic OR.

Towards a safer culture: implementing multidisciplinary simulation-based team training in New Zealand operating theatres - a framework analysis

AIM

NetworkZ is a simulation-based multidisciplinary team-training programme designed to enhance patient safety by improving communication and teamwork in operating theatres (OTs). In partnership with the Accident Compensation Corporation, its implementation across New Zealand (NZ) began in 2017. Our aim was to explore the experiences of staff - including the challenges they faced - in implementing NetworkZ in NZ hospitals, so that we could improve the processes necessary for subsequent implementation.

METHOD

We interviewed staff from five hospitals involved in the initial implementation of NetworkZ, using the Organising for Quality model as the framework for analysis. This model describes embedding successful quality improvement as a process of overcoming six universal challenges: structure, infrastructure, politics, culture, motivation and learning.

RESULTS

Thirty-one people participated. Structural support within the hospital was considered essential to maintain staff enthusiasm, momentum and to embed the programme. The multidisciplinary, simulation-based approach to team training was deemed a fundamental infrastructure for learning, with participants especially valuing the realistic in situ simulations and educational support. Participants reported positive changes to the OT culture as a result of NetworkZ and this realisation motivated its implementation. In sites with good structural support, NetworkZ implementation proceeded quickly and participants reported rapid cultural change towards improved teamwork and communication in their OTs.

CONCLUSION

Implementation challenges exist and strategies to overcome these are informing future implementation of NetworkZ. Embedding the programme as business as usual across a nation requires significant and sustained support at all levels. However, the potential gains in patient safety and workplace culture from widespread multidisciplinary team training are substantial. Trial registration number ACTRN12617000017325.

Development and Implementation of the Portable Operating Room Tracker App With Vital Signs Streaming Infrastructure: Operational Feasibility Study

Background

In the perioperative environment, a multidisciplinary clinical team continually observes and evaluates patient information. However, data availability may be restricted to certain locations, cognitive workload may be high, and team communication may be constrained by availability and priorities. We developed the remote Portable Operating Room Tracker app (the telePORT app) to improve information exchange and communication between anesthesia team members. The telePORT app combines a real-time feed of waveforms and vital signs from the operating rooms with messaging, help request, and reminder features.

Objective

The aim of this paper is to describe the development of the app and the back-end infrastructure required to extract monitoring data, facilitate data exchange and ensure privacy and safety, which includes results from clinical feasibility testing.

Methods

telePORT’s client user interface was developed using user-centered design principles and workflow observations. The server architecture involves network-based data extraction and data processing. Baseline user workload was assessed using step counters and communication logs. Clinical feasibility testing analyzed device usage over 11 months.

Results

telePORT was more commonly used for help requests (approximately 4.5/day) than messaging between team members (approximately 1/day). Passive operating room monitoring was frequently utilized (34% of screen visits). Intermittent loss of wireless connectivity was a major barrier to adoption (decline of 0.3%/day).

Conclusions

The underlying server infrastructure was repurposed for real-time streaming of vital signs and their collection for research and quality improvement. Day-to-day activities of the anesthesia team can be supported by a mobile app that integrates real-time data from all operating rooms.

Communication and relationship dynamics in surgical teams in the operating room: an ethnographic study

BACKGROUND

In surgical teams, health professionals are highly interdependent and work under time pressure. It is of particular importance that teamwork is well-functioning in order to achieve quality treatment and patient safety. Relational coordination, defined as "communicating and relating for the purpose of task integration," has been found to contribute to quality treatment and patient safety. Relational coordination has also been found to contribute to psychological safety and the ability to learn from mistakes. Although extensive research has been carried out regarding relational coordination in many contexts including surgery, no study has explored how relational coordination works at the micro level. The purpose of this study was to explore communication and relationship dynamics in interdisciplinary surgical teams at the micro level in contexts of variable complexity using the theory of relational coordination.

METHODS

An ethnographic study was conducted involving participant observations of 39 surgical teams and 15 semi-structured interviews during a 10-month period in 2014 in 2 orthopedic operating units in a university hospital in Denmark. A deductively directed content analysis was carried out based on the theory of relational coordination.

RESULTS

Four different types of collaboration in interdisciplinary surgical teams in contexts of variable complexity were identified representing different communication and relationship patterns: 1) proactive and intuitive communication, 2) silent and ordinary communication, 3) inattentive and ambiguous communication, 4) contradictory and highly dynamic communication. The findings suggest a connection between communication and relationship dynamics in surgical teams and the level of complexity of the surgical procedures performed.

CONCLUSION

The findings complement previous research on interdisciplinary teamwork in surgical teams and contribute to the theory of relational coordination. The findings offer a new typology of teams that goes beyond weak or strong relational coordination to capture four distinct patterns of relational coordination. In particular, the study highlights the central role of mutual respect and presents proposals for improving relational coordination in surgical teams.

Difficulties and possibilities in communication between referring clinicians and radiologists: perspective of clinicians

Purpose

To investigate modes and quality of interprofessional communication between clinicians and radiologists, and to identify difficulties and possibilities in this context, as experienced by referring clinicians.

Patients and methods

Focus group interviews with 22 clinicians from different specialties were carried out. The leading question was: "How do you experience communication, verbal and nonverbal, between referring clinicians and radiologists?" Content analysis was used for interpretation of data.

Results

Overall, referring clinicians expressed satisfaction with their interprofessional communication with radiologists, and digital access to image data was highly appreciated. However, increased reliance on digital communication has led to reduced face-to-face contacts between clinicians and radiologists. This seems to constitute a potential threat to bilateral feedback, joint educational opportunities, and interprofessional development. Cumbersome medical information software systems, time constraints, shortage of staff, reliance on teleradiology, and lack of uniform format of radiology reports were mentioned as problematic. Further implementation of structured reporting was considered beneficial.

Conclusion

Deepened face-to-face contacts between clinicians and radiologists were considered prerequisites for mutual understanding, deepened competence and mutual trust; a key factor in interprofessional communication. Clinicians and radiologists should come together in order to secure bilateral feedback and obtain deepened knowledge of the specific needs of subspecialized clinicians.

Relationships Between Expertise, Crew Familiarity and Surgical Workflow Disruptions: An Observational Study

BACKGROUND

Teamwork is an essential factor in reducing workflow disruption (WD) in the operating room. Team familiarity (TF) has been recognized as an antecedent to surgical quality and safety. To date, no study has examined the link between team members' role and expertise, TF and WD in surgical setting. This study aimed to examine the relationships between expertise, surgeon-scrub nurse familiarity and WD.

METHODS

We observed a convenience sample of 12 elective neurosurgical procedures carried out by 4 surgeons and 11 SN with different levels of expertise and different degrees of familiarity between surgeons and SN. We calculated the number of WD per unit of coding time to control for the duration of operation. We explored the type and frequency of WD, and the differences between the surgeons and SN. We examined the relationships between duration of WD, staff expertise and surgeon-scrub nurse familiarity.

RESULTS

9.91% of the coded surgical time concerned WD. The most frequent causes of WD were distractions (29.7%) and colleagues' interruptions (25.2%). This proportion was seen for SN, whereas teaching moments and colleagues' interruptions were the most frequent WD for surgeons. The WD was less high among expert surgeons and less frequent when surgeon was familiar with SN.

CONCLUSIONS

The frequency of WD during surgical time can compromise surgical quality and patient safety. WD seems to decrease in teams with high levels of surgeon-scrub nurse familiarity and with development of surgical expertise. Favoring TF and giving feedback to the team about WD issues could be interesting ways to improve teamwork.

Discordance in Information Exchange Between Providers During Care Transitions for Surgical Patients

BACKGROUND

The exchange of health information between primary care providers (PCPs) and surgeons is critical during transitions of care for older patients with multiple comorbidities; however, it is unknown to what extent this process occurs. This study was designed to characterize the extent to which factors associated with older patient's recovery, such as functional status, cognitive status, social status, and emotional factors, are shared among PCPs and surgical providers during care transitions.

MATERIALS AND METHODS

We prospectively identified 15 patients aged over 60 y with ≥3 comorbidities referred for general and vascular surgery procedures at a Veterans Administrative and academic medical center. Semistructured Critical Decision Method interviews were conducted with patients along with their surgical providers and referring PCPs. Thematic content analysis was performed independently by five reviewers on the cognitive processes associated with functional status, cognitive status, social status, and emotional factors. Interrater reliability between providers and patients was assessed using Cohen's kappa.

RESULTS

Forty-seven Critical Decision Method interviews were conducted, which included 20 paired interviews between a PCP and a surgeon and 16 paired interviews that involved a patient and a provider. The majority of patients reported experiencing poor information exchange between their PCP and surgeon (58%) and feeling they were primarily responsible for communicating their own health information during care transitions (67%). In paired interviews between PCPs and surgeons, there was nearly perfect agreement for the shared knowledge of cognitive (kappa: 0.83) and emotional (kappa 1) factors. In contrast, there was only minimal agreement for shared knowledge of functional status (kappa 0.38) and social status (kappa: 0.34).

CONCLUSIONS

Information exchange between PCPs and surgical providers is often discordant during transitions of surgical care for medically complex older patients, particularly when it pertains to communicating their functional or social status.

Team composition and staff roles in a hybrid operating room: A prospective study using video observations

AIM

The aim of the study was to evaluate team composition and staff roles in a hybrid operating room during endovascular aortic repairs.

DESIGN

Quantitative descriptive design.

METHODS

Nine endovascular aortic repairs procedures were video-recorded between December 2014 and September 2015. The data analysis involved examining the work process, number of people in the room and categories of staff and their involvement in the procedure.

RESULTS

The procedures were divided into four phases. The hybrid operating room was most crowded in phase 3 when the skin wound was open. Some staff categories were in the room for the entire procedure even if they were not actively involved. The largest number of people simultaneously in the room was 14.

Surgical safety in radical cystectomy: the anesthetist's point of view-how to make a safe procedure safer

PURPOSE

The aim of this review is to present an anesthesiological overview on surgical safety for radical cystectomy implementing the cornerstones of today's rapidly evolving field of perioperative medicine.

METHODS

This is a narrative review of current perioperative medicine and surgical safety concepts for major surgery in general with special focus on radical cystectomy.

RESULTS

The tendency for perioperative care and surgical safety is to consider it a continuous proactive pathway rather than a single surgical intervention. It starts at indication for surgery and lasts until full functional recovery. Preoperative optimization leads to superior outcome by mobilizing and/or increasing physiological reserve. Multidisciplinary teamwork involving all the relevant parties from the beginning of the pathway is crucial for outcome rather than an isolated specialist approach. This fact has gained importance in times of an ageing frail population and rising health care cost. We also present our 2019 Cystectomy Enhanced Recovery Approach for optimization of perioperative care for open radical cystectomy in a high caseload center.

CONCLUSIONS

With the implementation of in itself simple but crucial steps in perioperative medicine such as multimodal prehabilitation, safety checks, better perioperative monitoring and enhanced recovery concepts, even complex surgical procedures such as radical cystectomy can be performed safer. Emphasis has to be laid on a more global view of the patients' path through the perioperative process than on the surgical procedure alone.

I Hear You, but Do I Understand? The Relationship of a Shared Professional Language With Quality of Care and Job Satisfaction

In various industries, individuals from different professions have to work together in a team to achieve their collective goal. Having gone through different educations, team members speak different professional languages, which poses a challenge to communication, and coordination in interprofessional teams. A shared language is believed to improve collaboration. In this study, we examine if a shared language in interprofessional healthcare teams is associated with better relational coordination and if both are connected to higher quality of care as well as job satisfaction of the staff. We shed light on possible mechanisms between shared language, and quality of care and job satisfaction, respectively, investigating relational coordination and psychological safety as mediators. We surveyed 197 healthcare workers (HCWs) from different professions in three rehabilitation centers in Switzerland. Multiple regression analyses showed that shared language was positively related to perceived quality of care and job satisfaction. Moreover, we found evidence for a serial mediation of these relationships by relational coordination and psychological safety. We discuss implications for healthcare and other types of interprofessional teams.

Using Incident Reports to Assess Communication Failures and Patient Outcomes

INTRODUCTION

Communication failures pose a significant threat to the quality of care and safety of hospitalized patients. Yet little is known about the nature of communication failures. The aims of this study were to identify and describe types of communication failures in which nurses and physicians were involved and determine how different types of communication failures might affect patient outcomes.

METHODS

Incident reports filed during fiscal year 2015-2016 at a Midwestern academic health care system (N = 16,165) were electronically filtered and manually reviewed to identify reports that described communication failures involving nurses and physicians (n = 161). Failures were categorized by type using two classification systems: contextual and conceptual. Thematic analysis was used to identify patient outcomes: actual or potential harm, patient dissatisfaction, delay in care, or no harm. Frequency of failure types and outcomes were assessed using descriptive statistics. Associations between failure type and patient outcomes were evaluated using Fisher's exact test.

RESULTS

Of the 211 identified contextual communication failures, errors of omission were the most common (27.0%). More than half of conceptual failures were transfer of information failures (58.4%), while 41.6% demonstrated a lack of shared understanding. Of the 179 identified outcomes, 38.0% were delays in care, 20.1% were physical harm, and 8.9% were dissatisfaction. There was no statistically significant association between failure type category and patient outcomes.

CONCLUSION

It was found that incident reports could identify specific types of communication failures and patient outcomes. This work provides a basis for future intervention development to prevent communication-related adverse events by tailoring interventions to specific types of failures.

Teamwork in healthcare: Key discoveries enabling safer, high-quality care

Few industries match the scale of health care. In the United States alone, an estimated 85% of the population has at least 1 health care encounter annually and at least one quarter of these people experience 4 to 9 encounters annually. A single visit requires collaboration among a multidisciplinary group of clinicians, administrative staff, patients, and their loved ones. Multiple visits often occur across different clinicians working in different organizations. Ineffective care coordination and the underlying suboptimal teamwork processes are a public health issue. Health care delivery systems exemplify complex organizations operating under high stakes in dynamic policy and regulatory environments. The coordination and delivery of safe, high-quality care demands reliable teamwork and collaboration within, as well as across, organizational, disciplinary, technical, and cultural boundaries. In this review, we synthesize the evidence examining teams and teamwork in health care delivery settings in order to characterize the current state of the science and to highlight gaps in which studies can further illuminate our evidence-based understanding of teamwork and collaboration. Specifically, we highlight evidence concerning (a) the relationship between teamwork and multilevel outcomes, (b) effective teamwork behaviors, (c) competencies (i.e., knowledge, skills, and attitudes) underlying effective teamwork in the health professions, (d) teamwork interventions, (e) team performance measurement strategies, and (f) the critical role context plays in shaping teamwork and collaboration in practice. We also distill potential avenues for future research and highlight opportunities to understand the translation, dissemination, and implementation of evidence-based teamwork principles into practice. (PsycINFO Database Record

Association Between Hospital Safety Culture and Surgical Outcomes in a Statewide Surgical Quality Improvement Collaborative

BACKGROUND

The "safety culture" within hospital systems is increasingly recognized as important to delivery of high-quality care. We examine the safety culture in a statewide hospital quality improvement collaborative and its associations with surgical outcomes.

STUDY DESIGN

A modified Safety Attitudes Questionnaire was sent to administrators, quality improvement teams, nurses, anesthesiologists, and surgeons in 49 hospitals participating in the Illinois Surgical Quality Improvement Collaborative in 2015. Associations between positive safety culture, as measured by percentage of positive responses on the Safety Attitudes Questionnaire, and the following NSQIP 30-day adverse outcomes: hospital-level risk-adjusted morbidity, mortality, death, or serious morbidity and readmission rates. Linear regression models with hospitals clustered by system were used to assess the relationship between safety culture and patient outcomes.

RESULTS

Operating room safety culture scores were highest (97.7% positive) compared with the other domains, and ratings of hospital management were lowest (75.9% positive). Hospital administrators consistently had the most positive perception of the safety culture (90.5% positive) and front-line providers were less positive: physicians (85.3%), advanced practice providers (88.1%), and nurses (80%). Teamwork was rated as a strength by patient care providers (physicians 88.3%, advanced practice providers 90.2%, and nurses 82.2%), but was perceived as weakest by administrators. Higher percentage of positive Safety Attitudes Questionnaire responses was significantly associated with lower risk of postoperative morbidity (p = 0.007) and death or serious morbidity (p = 0.04). No significant association between safety culture and the risk of mortality (p = 0.23) or readmissions (p = 0.52) was observed.

CONCLUSIONS

Hospital safety culture can influence certain surgical patient outcomes. Improving the safety culture within a hospital can represent a previously unrecognized approach that can be leveraged to strengthen surgical quality improvement efforts at the hospital level.

Time-motion analysis examining of the impact of Medic Bleep, an instant messaging platform, versus the traditional pager: a prospective pilot study

Objectives

Efficient and accurate communication between healthcare professionals (HCPs) serves as the backbone to safe and efficient care delivery. Traditional pager-based interpersonal communication may contribute to inefficient communication practices and lapses in medical care.

Methods

This study aimed to examine the impact of Medic Bleep, a National Health Service (NHS) information governance-compliant instant messaging application, in an NHS Hospital Trust. We examined Medic Bleep’s impact on participant time and workflow using time–motion methodology. Cohorts of doctors and nurses using both Medic Bleep and the traditional pager were compared. Secondary endpoints of our study were to assess whether efficient communications could lead to better resource utilisation, patient safety as well as better quality of work life for the end user.

Results

Assimilation of Medic Bleep corresponded to a reduction in mean task-duration that was statistically significant (p < 0.05) for To Take Out (TTO) and Patient Review categories. Nurses saved an average of 21 minutes per shift (p < 0.05), whereas doctors saved an average of 48 minutes (p < 0.05) per shift. Qualitative analysis suggested that HCPs benefited from better work prioritisation, collaboration and reduced medical errors enabled by an auditable communication workflow.

Conclusion

Medic Bleep reduced time spent on the tasks requiring interpersonal communication. Efficiencies were seen in Discharge Patient Flow, Patient Review and TTO categories. This improved HCP availability and response times to the benefit of patients. End users revealed that Medic Bleep had a positive effect on quality of work life.

Medical Errors Cause Harm in Veterinary Hospitals

Medical errors are a leading cause of mortality in human medicine. In contrast, errors in veterinary medicine are rarely discussed, and there is little known about their nature and frequency. This study aimed to evaluate the type and severity of medical errors reported in three veterinary hospitals. The voluntary online incident reporting systems of a small animal teaching hospital, large animal teaching hospital, and small animal multi-specialty practice were reviewed. Reports were included if they were entered between February 2015 and March 2018, and involved an incident pertaining to patient safety. The reporting systems classified errors into the following categories: drug, iatrogenic, system, communication, lab, oversight, staff, or equipment errors. In addition, all incidents were classified as resulting in either a near miss, harmless hit, adverse incident, or unsafe condition. Adverse incidents were further evaluated retrospectively for error severity. A total of 560 incident reports were included for analysis. Drug errors were the most frequently reported in all three hospitals, followed by failures of communication. Errors most commonly reached patients without causing harm (45%); however, 15% of all incidents resulted in patient harm. Eight percent of patients harmed suffered permanent morbidity or death. A higher proportion of adverse incidents were reported in the small animal teaching hospital than in the other two practice settings. This study demonstrates that medical errors have a substantial impact on veterinary patients. Establishing that drug and communication errors are most frequent in a variety of hospitals is the first step toward interventions to improve patient safety and outcomes in veterinary medicine.

Training of laparoscopic novices both individually and in dyads using a simulation task

Non-technical skill training improves outcomes in surgery and quantifying the effects of this training may aid in designing surgical teaching models. In our study, 12 novices performed a wire-chaser laparoscopic task in 9 training sessions, working both as individuals and dyads. Task duration (p < 0.001), number of ring-wire contacts (p < 0.001), total duration of contact (p < 0.001), and number of pick up attempts (p = 0.044) all showed significant improvement in both groups with no significant difference in the learning curves between individuals and dyads. There was, however, an interaction effect for the number of ring-wire contacts (p = 0.027) whereby the number of contacts dropped more dramatically among dyads. Dyads also performed significantly more anticipatory movements than individuals (p = 0.005). Novices performed similarly when working individually and as dyads, suggesting that the need for collaboration neither hindered nor helped performance for our particular task.