Operating Room Safety B Boulanger MD
Many facets of a successful operating room Efficiency First case starts, TO time, prime time utilization, block utilization, case cancellations, case delays, case cart accuracy Financial Cost per case, contrib margin per case, overtime, inventory Service Patient satisfaction, surgeon satisfaction, staff satisfaction Quality and Safety
Operating Room Safety Oh damn.this is going to be boring
Outline Why talk about OR safety? Do we have a problem? Is there anywhere we can look for help? Culture of Safety
As surgeons, what do we want the operating room to be? Efficient Easy access to schedule cases Have the supplies and instruments I need when I need them Safe
Who s safety are we talking about? Surgical Team Surgeon safety Nursing safety Anesthesia safety OR Techs/Aides safety Environmental Services Safety Patient safety
Let s ask some questions Do you want your patients to have surgery in a safe OR? Do you want to work in a safe OR? Do you believe that surgeons should provide leadership in ensuring patient safety in the OR? Do you believe YOU will benefit from working in a safe OR?
How do you benefit from surgery that is safe for your patients? Less morbidity and mortality Improved quality of your work Practice growth Less liability Greater efficiency
We have a problem Kohn LT, Corrigan JM, Donaldson MD: To Err is Human: Building a Safer Health System. Committee on Quality of Health Care in America, Institute of Medicine. Washington DC National Academy Press; 1999
Wrong patient Wrong operation Wrong side/site You have just created a world of hurt for the patient AND yourself
We have a problem 1998 JC issues an alert on wrong site surgery 2000 150 cases of wrong site/person/procedure surgery in JC database 41% ortho, 20% gen surg, 14% neurosurgery In all cases, poor communication between members of the team and between the team and the patient
ACS Statement on ensuring correct patient, correct site, and correct procedure surgery. Oct 2002 The American College of Surgeons (ACS) recognizes patient safety as being an item of the highest priority and strongly urges individual hospitals and health organizations to develop guidelines to ensure correct patient, correct site, and correct procedure surgery PROBLEM PERSISTS.
We have a problem 2004 JC develops and implements the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery. Pre-operative verification process Site marking Time out
Operating Room Errors: It s a long list Wrong patient Wrong operation Wrong site or side Unexpected intra-operative death Loss of airway Intra-operative complications Retained foreign bodies OR fires Mishandling of surgical specimens Patient injury due to positioning or burns Medication errors Transfusion mishaps Etc
When is my patient safe in the OR? Never errors can and do occur!!
Safety Success Stories US Nuclear Submarine Program Alcoa Dupont Commercial Airline Industry
Tenerife the crash that changed the airline industry Deadliest crash in aviation history 538 fatalities 1977, Tenerife Island, Canary Islands Collision of a KLM Boeing 747 and a Pan Am Boeing 747
Captain Jacob van Zanten
Tenerife the crash that changed the airline industry Cockpit KLM 747 Captain Jacob van Zanten - a star Copilot first officer Flight engineer second officer Dense fog, one runway Pan Am 747 on runway out of sight of KLM 747
Tenerife the crash that changed the airline industry Captain van Zanten puts KLM plane on runway and is in a rush to take off Copilot says with great hesitation wait we do not have clearance yet! Air traffic control clearance given but takeoff clearance not given and captain begins throttling up Copilot rushes to try and get clearance, communication poor with tower but copilot gives pilot the OK to takeoff. Copilot focuses on his duties to assist the captain and says nothing
Tenerife the crash that changed the airline industry At 45 knots, the very junior flight engineer speaks up lightly and says is he not clear then, that Pan Am? Pilot and copilot say What? At 80 knots, the flight engineer repeats in a soft voice is he not clear then, that Pan Am? Yes snaps Captain van Zanten
At 112 knots, Captain van Zanten sees Pan Am 747 sideways on runway and tries to leapfrog over the plane. collision occurs..538 fatalities.
Why? Several factors The myth that senior airline captains are infallible; avoiding mistakes due to their experience, strength of personality and wits. Assumption - a person of such stature is presumed to be perfect Culture of the airline cockpit before Tenerife Misunderstood words or phrases Lack of communication
The Response 1978 NASA research indicates that majority of airline disasters NOT due to pilots lack of technical skill or mechanical failure BUT from errors associated with breakdowns in: Communication Leadership Teamwork
The Response Cockpit or Crew Resource Management (CRM) evolved: Focus on human and systems issues Work culture within cockpit gradually modified All members of crew empowered to provide feedback, opinion, ask questions, hard stop Error management Standardized checklists, forcing functions and language of cockpit communications
Think about this Technical excellence alone does not always guarantee a positive outcome
Think about this Being a good leader and getting the most from a team are not directly linked to your technical expertise
The Impact of Crew Resource Management (CRM) on the Commercial Airline Industry Improved cockpit team interactions Fewer errors Better morale (lower staff turnover) Commercial flight more cost effective Overall rate of airline incidents has declined Commercial aviation is the safest form of transportation on a per mile basis
Capt Sullenberger He was instrumental in the development and implementation of the Crew Resource Management (CRM) course used at his airline and has taught the course to hundreds of his colleagues. His interaction with co-pilot Jeffrey Skiles, the cabin crew and air traffic controllers is a textbook example of coordination, delegation and decision-making. Capt Sullenberger later said, "It was very quiet as we worked, my co-pilot and I. We were a team.
The relationship between human error and established systems is complex Attempted Takeoff From Wrong Runway Comair Flight 5191 Bombardier CL-600-2B19, N431CA Lexington, Kentucky August 27, 2006
NTSB report - 5191 The flight crewmembers failed to recognize that they were initiating a takeoff on the wrong runway because they did not crosscheck and confirm the airplane s position on the runway before takeoff and they were likely influenced by confirmation bias.
NTSB report - 5191 The flight crew s noncompliance with standard operating procedures, including the captain s abbreviated taxi briefing and both pilots non-pertinent conversation, most likely created an atmosphere in the cockpit that enabled the crew s errors.
NTSB report - 5191 The National Transportation Safety Board determines that the probable cause of this accident was the flight crewmembers failure to use available cues and aids to identify the airplane s location on the airport surface during taxi and their failure to cross-check and verify that the airplane was on the correct runway before takeoff. Contributing to the accident were the flight crew s nonpertinent conversation during taxi, which resulted in a loss of positional awareness
Wilbur Wright in a letter to his father, Sept 1900 In flying I have learned that carelessness and overconfidence are usually far more dangerous than deliberately accepted risks
Our Tenerife Kohn LT, Corrigan JM, Donaldson MD: To Err is Human: Building a Safer Health System. Committee on Quality of Health Care in America, Institute of Medicine. Washington DC National Academy Press; 1999
What makes an OR safer? Less Errors
OR Safety Pyramid These we all hear about Errors that cause harm Errors Near misses or close calls Process Problems Your OR needs to have a system to capture these Your OR needs to capture signals that tell us we may have these
Errors Habits and Routines Protect Us Errors depend on two kinds of failures: an error of execution an error of planning Source: Managing the Risks of Organizational Accidents, By: James Reason Slips, lapses and mistakes - part of humanity - exacerbated by anxiety, fatigue and fear
Avoid hazardous situations by design
Safety in the OR As surgeons we need to perform technically safe operations. Systems in place to try and ensure technical competence Residency training programs Board certification and re-certification CME requirements Peer review process Chief of Service, Chief of Surgery Chief of Staff or Chief Medical Officer Medicolegal
A prospective study of patient safety in the operating room. Christian et al, Surgery 2006 observational study of operating rooms at Brigham and Womens Hospital in all cases observed, problems existed that had a measurable negative impact on team performance and patient safety greatest threats to patient safety in the OR communication breakdown information loss increased workload competing tasks
Airline Cockpit and the Operating Room Similarities High risk Highly complex technical work Intelligent motivated people Teams
Airline cockpit and the Operating Room Differences In crash, many people die at once Pilots are first at the scene of a crash Airline pilots have strict duty hour restrictions New airline hires, incl captains, fly with check airmen Below 10,000 feet airlines maintain a sterile cockpit Pilots avoid punishment if they promptly report errors, surgeons fear litigation and loss of licensure Airlines learned long ago that certain weather conditions make a safe landing unlikely.surgeon can operate on anyone they want to!!
American College of Surgeons Involved in surgical safety since 1913 Helped organize the Joint Commission on Accreditation of Healthcare Organizations in 1953 1979 published first edition of Patient Safety Manual
Surgical Patient Safety: Essential Information for Surgeons in Today's Environment Edited by Barry M. Manuel, MD, FACS, and Paul F. Nora, MD, FACS Topics covered: Error Detection, Analysis, and Reporting Operating at the Sharp End: The Human Factors of Complex Technical Work and Its Implications for Patient Safety Wrong-Site Surgery Organizing for Patient Safety at the Institutional Level Accountability in Surgery Enhancing Patient Safety Through Educational Interventions The Future of Surgical Patient Safety: Ensuring Surgical Patient Safety Through Quality Improvement--National Initiatives and the Role of the American College of Surgeons
American College of Surgeons General sessions and post-graduate courses at clinical congresses on applying the aviation model to the operating room
Bulletin of ACS series - OR Safety and Crew Resource Management (CRM) February, June and November 2006 Gerald Healy MD FACS, Chair of Board of Regents Jack Barker PhD, Airbus first officer for United Airlines Capt Gregory Madonna, 737 captain
Seven principles (CRM) Bulletin ACS June 2006 1. Command one final decision maker who must be willing to foster the team and accept responsibility and accountability for their team s actions. 2. Leadership defined by commanders willingness to let team members exercise their rights and responsibilities to ensure a safe and positive outcome. Although there is only one commander any member of a team can show leadership. Surgeons who encourage teamwork are MORE respected.
You can still be like this guy!
You can still be like this guy! But you cannot do it all alone You need a supportive system and an engaged OR team that will provide a safe environment for your patient
Seven principles (CRM) Bulletin ACS June 2006 3. Communication teams that fail to communicate are doomed to negative results and errors. Adverse OR events often related to poor communication due to factors such as steep hierarchies, stress and cultural differences 4. Situational awareness an effective leader relies on team to promote situational awareness through effective communication about what is occurring. Why didn t you tell me!
Sometimes there is more communication here.
Seven principles (CRM) Bulletin ACS June 2006 5. Workload management organizing tasks such that there is equitable distribution amongst team members. Plan the work and work the plan 6. Resource management optimal use of all information, data, assistance available to the team. Ensuring the presence of needed resources.
Seven principles (CRM) Bulletin ACS June 2006 7. Decision making Collaborative discouraged in high performance teams Unilateral fast but is a problem if leader is not aware of all information or makes incorrect decision Consultative most effective in high performance teams. Leader must know when to stop gathering data.
The American College of Surgeons regards patient safety as a top priority and strongly urges individual hospitals and health care organizations to develop guidelines to ensure optimal patient safety in the operating room. The use of a team approach has been shown to be highly effective. However, this approach requires the engagement of all parties involved in the surgical process. Since lack of communication and failure to coordinate care are the most common causes of medical errors, the incorporation of team-based practice is desirable. Board of Regents, October 2008
OR Team should be: Patient-focused Not surgeon-focused Not workflow-focused Not break-focused Not specialty-focused Not budget-focused Not facebook-focused!
If I had the same OR team with me every day I would not have to worry about safety Aviation studies show that: Fixed teams tend to make more mistakes, especially on routine flights. Worst flight errors made by newly formed crews working together for first or second time Formed teams tend to have the best outcomes
Aviation safety and the Operating Room Can Aviation-based Team Training Elicit Sustainable Behavioral Change? Arch Surg Dec 2009 Crew resource management (CRM) programs can influence personal behaviors and empowerment. Effects may take years to be ingrained into the culture.
What can we do to achieve a Culture of Safety in our ORs Commit to safety Focus on safe operations Recognize a high risk situation View safety as a system responsibility with individual accountability Surgeons provide leadership Encourage teamwork Collect data OR quality and safety committee Clarke J, ACS bulletin Nov 07
The OR as a Workplace
The OR as a Workplace
A fair and non-threatening workplace fosters safety (and efficiency) Nurses, surgeons, techs, anesthesia, environmental services, aides.everybody needs to feel engaged! Respect for co-workers Respect for their opinions, concerns Made to feel valued Encouraged to be both assertive and respectful Anybody can put a hard stop on a process
Conclusions The airline industry has taught us that: The most experienced, most skilled, most dedicated, most charming pilot (surgeon) can make a bad mistake. Even the best pilot (surgeon) will not be able to single handedly prevent all errors made in the cockpit (OR)
Conclusions An optimal error reduction (safety) system involves: A team approach you cannot do it alone A fair and non-threatening workplace Standardized approaches such as Time out Rigorous and real time scrutiny of errors, close calls and near misses Don t play the blame game - Hold individuals responsible for recklessness and foster personal accountability BUT hold the system responsible for errors. A constant unrelenting desire to improve
Strive for a Culture of Safety in our ORs It s good for your patients It will minimize YOUR chance of getting into trouble It will minimize the chance of someone else getting YOU into trouble It will make the OR a more efficient place for you to work