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Locating Errors Through Networked Surveillance: A Multimethod Approach to Peer Assessment, Hazard Identification, and Prioritization of Patient Safety Efforts in Cardiac Surgery

OBJECTIVES

The objectives were to develop a scientifically sound and feasible peer-to-peer assessment model that allows health-care organizations to evaluate patient safety in cardiovascular operating rooms and to establish safety priorities for improvement.

METHODS

The locating errors through networked surveillance study was conducted to identify hazards in cardiac surgical care. A multidisciplinary team, composed of organizational sociology, organizational psychology, applied social psychology, clinical medicine, human factors engineering, and health services researchers, conducted the study. We used a transdisciplinary approach, which integrated the theories, concepts, and methods from each discipline, to develop comprehensive research methods. Multiple data collection was involved: focused literature review of cardiac surgery-related adverse events, retrospective analysis of cardiovascular events from a national database in the United Kingdom, and prospective peer assessment at 5 sites, involving survey assessments, structured interviews, direct observations, and contextual inquiries. A nominal group methodology, where one single group acts to problem solve and make decisions was used to review the data and develop a list of the top priority hazards.

RESULTS

The top 6 priority hazard themes were as follows: safety culture, teamwork and communication, infection prevention, transitions of care, failure to adhere to practices or policies, and operating room layout and equipment.

CONCLUSIONS

We integrated the theories and methods of a diverse group of researchers to identify a broad range of hazards and good clinical practices within the cardiovascular surgical operating room. Our findings were the basis for a plan to prioritize improvements in cardiac surgical care. These study methods allowed for the comprehensive assessment of a high-risk clinical setting that may translate to other clinical settings.

Realizing Improved Patient Care through Human-centered Operating Room Design

Background:

Human factors engineering has allowed a systematic approach to the evaluation of adverse events in a multitude of high-stake industries. This study sought to develop an initial methodology for identifying and classifying flow disruptions in the cardiac operating room (OR).

Methods:

Two industrial engineers with expertise in human factors workflow disruptions observed 10 cardiac operations from the moment the patient entered the OR to the time they left for the intensive care unit. Each disruption was fully documented on an architectural layout of the OR suite and time-stamped during each phase of surgery (preoperative [before incision], operative [incision to skin closure], and postoperative [skin closure until the patient leaves the OR]) to synchronize flow disruptions between the two observers. These disruptions were then categorized.

Results:

The two observers made a total of 1,158 observations. After the elimination of duplicate observations, a total of 1,080 observations remained to be analyzed. These disruptions were distributed into six categories such as communication, usability, physical layout, environmental hazards, general interruptions, and equipment failures. They were further organized into 33 subcategories. The most common disruptions were related to OR layout and design (33%).

Conclusions:

By using the detailed architectural diagrams, the authors were able to clearly demonstrate for the first time the unique role that OR design and equipment layout has on the generation of physical layout flow disruptions. Most importantly, the authors have developed a robust taxonomy to describe the flow disruptions encountered in a cardiac OR, which can be used for future research and patient safety improvements.

Quality, patient safety, and the cardiac surgical team

After more than a decade of attention, the risks inherent in cardiac surgery have been well documented, but examples of effective interventions to reduce this risk remain scarce. The need is great, because the patient population is vulnerable and the potential consequences of poor outcomes are ever present and significant. This article reviews a decade of discussion surrounding quality and safety issues in cardiac surgery, and concludes with examples of strategies that have shown great promise for improving cardiac surgery quality and safety.

The anesthesia team of the future

PURPOSE OF REVIEW

This review is aimed at highlighting the recent developments and opportunities that are likely to impact the anesthesia team of the future.

RECENT FINDINGS

The anesthesia team of the future aims to provide well tolerated, efficient, and cost-effective perioperative care. Certified and subspecialty trained anesthesiologists lead a diverse team of care providers in increasingly dissimilar environments. The spread of electronic health record systems has been the basis for the development of clinical decision support applications that promise to integrate quality control, enhanced efficiency, research opportunities, and improved patient care in the perioperative period. Perioperative epidemiology is a likely area of growth within the field of anesthesiology ultimately enabling the anesthesia team to translate precise real-time information into improved outcome.

SUMMARY

The anesthesia team of the future will require the anesthesiologist to provide expertise across the entire domain of perioperative medicine. Meaningful decision support systems rely on accurate data analysis and incorporation of current clinical guidelines and recommendations.