System Factors Affecting Patient Safety in the OR

Adams-McGavin, Robert C.; Jung, James J.; Dalen, Anne Sophie H M van; Grantcharov, Teodor P.; Schijven, Marlies P.

doi:10.1097/sla.0000000000003616

Cited by 22 publications

(26 citation statements)

References 31 publications

(66 reference statements)

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“…14 Previous attempts to capture this information in the operating room have occurred, most notably with black box technology. 15,16 In a prior analysis of a single operating room with this equipment installed, general laparoscopic surgery of only 4 surgeons was assessed to capture potential resilient, proactive safety behaviors. 15,16 In a given surgical case, a median of 12 resilient supports were identified per case, most commonly in the person or organization category.…”

Section: Discussionmentioning

confidence: 99%

“… 15 , 16 In a prior analysis of a single operating room with this equipment installed, general laparoscopic surgery of only 4 surgeons was assessed to capture potential resilient, proactive safety behaviors. 15 , 16 In a given surgical case, a median of 12 resilient supports were identified per case, most commonly in the person or organization category. 15 Although this begins to provide insight into resilient, proactive safety behaviors in the operating room, it focuses only on the surgical case itself, is limited to the staff in the room, and is technically challenging to implement.…”

Section: Discussionmentioning

confidence: 99%

“… 15 , 16 In a given surgical case, a median of 12 resilient supports were identified per case, most commonly in the person or organization category. 15 Although this begins to provide insight into resilient, proactive safety behaviors in the operating room, it focuses only on the surgical case itself, is limited to the staff in the room, and is technically challenging to implement. However, the Resilience Engineering Tool to Improve Patient Safety (RETIPS), which is an incident reporting structure to elicit narrative descriptions of clinical scenarios where safe, successful care was present to capture positive adaptations, is a more flexible approach.…”

Section: Discussionmentioning

confidence: 99%

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Clinicians’ Perspectives on Proactive Patient Safety Behaviors in the Perioperative Environment

et al. 2023

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ImportanceThe perioperative environment is hazardous, but patients remain safe with a successful outcome during their care due to staff adaptability and resiliency. The behaviors that support this adaptability and resilience have yet to be defined or analyzed. One Safe Act (OSA), a tool and activity developed to capture self-reported proactive safety behaviors that staff use in their daily practice to promote individual and team-based safe patient care, may allow for improved definition and analysis of these behaviors.ObjectiveTo thematically analyze staff behaviors using OSA to understand what may serve as the basis for proactive safety in the perioperative environment.Design, Setting, and ParticipantsThis qualitative thematic analysis included a convenience sample of perioperative staff at a single-center, tertiary care academic medical center who participated in an OSA activity during a 6-month period in 2021. All perioperative staff were eligible for inclusion. A combined deductive approach, based on a human factor analysis and classification framework, as well as an inductive approach was used to develop themes and analyze the self-reported staff safety behaviors.ExposuresThose selected to participate were asked to join an OSA activity, which was conducted in-person by a facilitator. Participants were to self-reflect about their OSA (proactive safety behavior) and record their experience as free text in an online survey tool.Main Outcome and MeasuresThe primary outcome was the development and application of a set of themes to describe proactive safety behaviors in the perioperative environment.ResultsA total of 140 participants (33 nurses [23.6%] and 18 trainee physicians [12.9%]), which represented 21.3% of the 657 total perioperative department full-time staff, described 147 behaviors. A total of 8 non–mutually exclusive themes emerged with the following categories and frequency of behaviors: (1) routine-based adaptations (46 responses [31%]); (2) resource availability and assessment adaptations (31 responses [21%]); (3) communication and coordination adaptation (23 responses [16%]); (4) environmental ergonomics adaptation (17 responses [12%]); (5) situational awareness adaptation (12 responses [8%]); (6) personal or team readiness adaptation (8 responses [5%]); (7) education adaptation (5 responses [3%]); and (8) social awareness adaptation (5 responses [3%]).Conclusions and RelevanceThe OSA activity elicited and captured proactive safety behaviors performed by staff. A set of behavioral themes were identified that may serve as the basis for individual practices of resilience and adaptability that promote patient safety.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Clinicians’ Perspectives on Proactive Patient Safety Behaviors in the Perioperative Environment

et al. 2023

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“…These data are analysed by expert raters and sophisticated artificial intelligence systems to provide a comprehensive surgical timeline, which makes it possible to identify the complete series of events leading to patient harm. 21,22 Despite study design limitations (e.g. retrospective accounts, lack of RCTs, self-reported experience), the reported associations between anaesthesia handovers and adverse patient safety are compelling given the large patient sample size (n¼605 678) and low risk of bias across studies.…”

Section: Discussionmentioning

confidence: 99%

Association of intraoperative anaesthesia handovers with patient morbidity and mortality: a systematic review and meta-analysis

Boet

Djokhdem

Leir

et al. 2020

British Journal of Anaesthesia

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Background: Handover of anaesthesia patient care during surgery is common; however, its association with patient outcome is unclear. This systematic review aimed to assess the impact of anaesthesia handover during surgery on patient outcome. Methods: All prospective and retrospective clinical studies specifically investigating the association of intraoperative transfer of anaesthesia care between anaesthesia providers in the operating room with patient morbidity and mortality were included. Searches were conducted from inception to April 24, 2019 in Medline, Medline in Process, CINAHL, and Embase. Reference lists of included studies were searched. Studies were assessed for eligibility and data were extracted by independent reviewers in duplicate with disagreements resolved by consensus or a third reviewer. Risk of bias was assessed in duplicate using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Data were summarised narratively given substantial heterogeneity. An exploratory metaanalysis was conducted using a random-effects model for a subset of comparable studies. Results: Eight studies met the inclusion criteria. Six studies focused on patients as the unit of analysis (n patients ¼605 678) and two focused on anaesthesia providers as the unit of analysis (n providers ¼307). Seven studies identified a relationship between anaesthesia handovers and adverse patient outcomes, whereas one suggested that handover may be beneficial to error detection or rectification. Included studies were of fair or good quality. Meta-analysis of four studies found a 40% increased risk of patients experiencing an adverse event when an anaesthesia handover occurs during the procedure (pooled risk ratio¼1.40; 95% confidence interval, 1.19 to 1.65; P<0.001; I 2 ¼98%). Conclusions: Intraoperative anaesthesia handovers generally increase morbidity and mortality for surgical patients but could have the potential to improve safety in certain contexts. Future research should determine the specific handover characteristics that impact safety.

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“…Additionally, this taxonomy can serve as the foundation for targeted QI and patient safety initiatives including video review. [12][13][14][15][16] By integrating this taxonomy into an institutional trauma video review program, reproducible and reliable analyses can occur. A common language and understanding of AEs applied during the video review process may allow for more accurate comparisons of trauma resuscitations and a more comprehensive understanding of the sequence of events leading to the AE.…”

Section: Meaning Of the Findingsmentioning

confidence: 99%

Defining adverse events during trauma resuscitation: a modified RAND Delphi study

Nolan

Petrosoniak

Hicks

et al. 2021

Trauma Surg Acute Care Open

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BackgroundThe majority of preventable adverse event (AEs) in trauma care occur during the initial phase of resuscitation, often within the trauma bay. However, there is significant heterogeneity in reporting these AEs that limits performance comparisons between hospitals and trauma systems. The objective of this study was to create a taxonomy of AEs that occur during trauma resuscitation and a corresponding classification system to assign a degree of harm.MethodsThis study used a modified RAND Delphi methodology to establish a taxonomy of AEs in trauma and a degree of harm classification system. A systematic review informed the preliminary list of AEs. An interdisciplinary panel of 22 trauma experts rated these AEs through two rounds of online surveys and a final consensus meeting. Consensus was defined as 80% for each AE and the final checklist.ResultsThe Delphi panel consisted of 22 multidisciplinary trauma experts. A list of 57 evidence-informed AEs was revised and expanded during the modified Delphi process into a finalized list of 67 AEs. Each AE was classified based on degree of harm on a scale from I (no harm) to V (death).DiscussionThis study developed a taxonomy of 67 AEs that occur during the initial phases of a trauma resuscitation with a corresponding degree of harm classification. This taxonomy serves to support a standardized evaluation of trauma care between centers and regions.Level of evidenceLevel 5.

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System Factors Affecting Patient Safety in the OR

Cited by 22 publications

References 31 publications

Clinicians’ Perspectives on Proactive Patient Safety Behaviors in the Perioperative Environment

Clinicians’ Perspectives on Proactive Patient Safety Behaviors in the Perioperative Environment

Association of intraoperative anaesthesia handovers with patient morbidity and mortality: a systematic review and meta-analysis

Defining adverse events during trauma resuscitation: a modified RAND Delphi study

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