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AAOS Now

Published 3/1/2011
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Stephen W. Harden

Surgeons and teamwork

Creating predictable improvements in safety, quality, and patient satisfaction

While performing a procedure to repair a disk herniation and remove an extruded fragment, Dr. Smith did the unthinkable (in his mind anyway); he made a mistake leading to a wrong surgery.

During his 30 years as a board-certified surgeon, Dr. Smith couldn’t imagine how a professional, conscientious surgeon could ever make such errors, and could not, in his wildest imagination, see himself making such an error—until the day he did.

What went wrong? As is often the case, many factors contributed to the error chain. First, he was distracted by events in his personal life and spent more time before the surgery talking about those events than he did in briefing his team about the upcoming procedure. Caught up in his own story, he gave scant attention to the time out—barely listening as the Circulator ticked off the required items. This was compounded by the fact that he wasn’t familiar with the operating room (OR) team, nor they with him.

Because the procedure was at a hospital where Dr. Smith rarely operated, he was not familiar with the room set. Confronted with an unusual room arrangement, Dr. Smith broke his normal pattern and helped drape the patient from the more accessible left side of the table, even though he intended to perform the procedure from the right side of the table. As the procedure progressed, he got distracted and never switched sides.

Not sure whether Dr. Smith knew something they didn’t, and unsure of his reaction if they voiced their concern, no one on the surgical team spoke up and asked an obvious question, “Shouldn’t you be making the incision on the right side?” Consequently, Dr. Smith never found and removed the extruded fragment. It had to be removed in a subsequent surgery after the mistake was discovered.

No one was shocked when Dr. Smith was sued by his patient. Embarrassed by the lawsuit and a totally preventable mistake, Dr. Smith will dwell on it the rest of his life. With deeper analysis, however, the outcome was not that surprising.

The type of error chain that led to Dr. Smith’s unthinkable error once plagued the U.S. commercial airline industry, leading to an unacceptably high rate of accidents and passenger deaths. Both NASA and the Military Inspector General identified that up to 80 percent of aircraft-related fatalities were a result of human error and poor teamwork.

The industry’s response was a program of teamwork training and checklist usage called Crew Resource Management (CRM). The decrease in accidents prompted the Federal Aviation Administration to mandate CRM programs at all major U.S. airlines, thus reducing critical errors and saving lives and money. CRM and other factors have reduced the death rate on U.S. major jet air carriers by 86 percent, to 19 deaths per billion passengers.

Applying the error-reduction strategies of the aviation safety model to surgery can be done in the following ways.

Interdisciplinary teamwork training
More than 20 years of research and experience in high-risk industries such as nuclear power and military operations demonstrate that team training overcomes the communication and collaboration causes of adverse events. This is also true in health care.

A recent RAND report reviewed 16 studies demonstrating the empirical relationship between teamwork behaviors and patient outcomes. Peer-reviewed literature shows the positive impact of teamwork training on patient care quality, safety, cost-effectiveness, and outcomes in ORs, as well as in inpatient medical and surgical wards and intensive care units. Effective teamwork improves clinical processes, reduces medical errors, improves surgical team performance, and encourages provider adherence to clinical guidelines.

Because poor communication among healthcare workers is the most common reason for preventable errors, causing nearly 70 percent of sentinel events and 75 percent of adverse events and close calls, physicians must have the interpersonal skills to make sure the team feels comfortable enough to speak up and address safety concerns during surgical procedures. Having these human factors skills is especially important for surgeons because ineffective teamwork is cited in 43 percent to 70 percent of closed malpractice claims. Communication failure in the OR was noted in 30 percent of cases by trained observers and is implicated in 43 percent of surgical adverse events.

Teamwork training for OR surgical teams improves preoperative procedure briefings and markedly reduces communication errors during cases. Effective OR teamwork enhances communication and collaboration, thereby eliminating the main causes of procedural errors.

Using a checklist
If Dr. Smith had used a checklist to conduct his preprocedure briefing, he would have reduced the opportunity for technical and communication errors and improved the information transfer during the surgery.

This is especially true when the surgeon personally leads the use of the checklist. Delegating this task to nurses reduces the effectiveness of the checklist in combating communication errors. Additionally, when the surgeon leads the OR team in using a preprocedure checklist,death rates and complications are reduced by more than a third; unplanned returns to the OR and surgical infections are reduced as well.

As noted on the bottom of the World Health Organization Surgical Safety Checklist, the most effective checklists are customized to fit local practice. Checklists should be created and updated by the teams that will actually use them. The best checklists function as standardized communication tools to promote information exchange and team cohesion and include the opportunity for the surgeon to conduct a quick team briefing.

Customized, site-specific preprocedure checklist briefings should cover the patient status, team members’ roles, the team’s plans, and any potential pitfalls. Surgeons can encourage “stop the line” communication by concluding the briefing with something like, “If you see, suspect, or feel that something is not right, I expect you to speak up.”

This type of thorough briefing promotes verbal communication and actively engages each team member to report his or her plan, concerns, and questions, behavior that would have broken the error chain causing the wrong surgery. These behaviors are critically important as the lack of team vigilance and cross checking contributes to more than half of the adverse events in the OR setting.

Dr. Smith, like many physicians, was probably concerned that using a checklist would take too much time. The evidence doesn’t confirm this concern. As surgeons gain experience in using a checklist, an effective briefing and checklist can be done in a minute or less, with zero delays in start times.

Additional benefits
Improved teamwork and communication among clinicians improves job satisfaction and reduces job stress and turnover. In the OR, preoperative briefings have been shown to increase team satisfaction. Additionally, surgical cases would proceed more efficiently as team briefings, using a script, reduce surgical flow disruptions.

Teamwork training and checklist usage improve surgeon, staff, and institutional efficiency. The number of “uneventful cases” (cases that are booked correctly, start on time, have no unplanned delays, and finish on time) increase, and case length and turnaround times decrease, even when the surgeon is learning to perform a new procedure.

Most importantly, patients benefit when healthcare workers participate in teamwork training and use checklists. Better teamwork performance among clinicians improves patient satisfaction. In addition, when surgical teams communicate and collaborate more effectively, patients benefit from lower hospital lengths of stay, greater gains in functional status, and reduced mortality and morbidity.

By investing time and effort in improving his communication and teamwork skills, along with the disciplined use of scripted briefings and checklists, Dr. Smith could have error-proofed his practice, and predictably improved outcomes quality, as well as patient safety and satisfaction. But the greatest benefit of all? A clear conscience, untainted by the bitter lifelong memory of a needless mistake.

Stephen W. Harden is president of LifeWings Partners LLC and a commercial pilot. He can be reached at sharden@saferpatients.com

Editor’s Note: Articles labeled Orthopaedic Risk Manager are presented by the Medical Liability Committee under the direction of contributing editor S. Jay Jayasankar, MD.

Articles are provided for general information and are not legal advice; for legal advice, consult a qualified professional.

E-mail your comments to feedback-orm@aaos.org or contact this issue’s contributors directly.

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