The 1999 Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System, estimated that up to one million preventable adverse events occurred in the United States each year, leading to 98,000 preventable deaths. The IOM suggested a focus—on human factors and a change in culture—for leadership, research, tools, and protocols to bring down those numbers. The medical industry was encouraged to learn from high-reliability organizations, such as the airline and the nuclear power industries, that focus heavily on communication, a shared mental model, and a culture of safety that expects and celebrates speaking-up and reporting problems or issues.
In 2012, the American Board of Orthopaedic Surgery (ABOS) reported on the results of a database search of 9,255 surgeons who applied for certification from 1999 through 2010. Of nearly 1.3 million procedures in the database, 76 wrong-site procedures were reported by a total of 61 surgeons.
Researchers noted that the rate of wrong-site procedures was not significantly different before and after the implementation of the Universal Protocol in 2004–2005. In fact, the site had been signed in 18 of 20 wrong-site surgeries reported after ABOS data collection on “Sign Your Site” began. The authors suggested the need for improved communication and shared responsibility for the surgical team.
An analysis of Sentinel Event categories (unintended retention of a foreign body; wrong-patient, wrong-site, wrong-procedure; operative/postoperative complication; delay in treatment) from 2010 through 2012 found that the root causes were communication, leadership, and human factors.
Addressing the problem
The Agency for Healthcare Research and Quality has developed TeamSTEPPS (Strategies and Tools to Enhance Performance and Patient Safety) to address the issue of surgical safety. TeamSTEPPS is based on the aviation industry’s crew resource management program and teaches four skills—leadership, communication, situation monitoring, and mutual support—that lead to team-related performance and outcomes (Fig. 1).
High-performing teams use the competencies of knowledge (a shared mental model), skills (leadership, communication, situational monitoring, and mutual support), and attitudes (mutual trust and team orientation) to produce the desired outcomes and performance. These outcomes are predicated on the following traits: adaptability, accuracy, productivity, efficiency, effectiveness, quality, and safety.
Communication is the process by which information is exchanged among individuals, departments, or organizations and is the lifeline of the team. For communication to be effective, it must be complete, clear, brief, and timely. Information exchange strategies from TeamSTEPPS include Situation-Background-Assessment-Recommendation (SBAR), call-out, call-back, and hand-off. These tools can ensure the team shares a common mental model.
Modeled on naval military procedures, SBAR is a framework for structured language that enables team members to effectively communicate information to one another. Unlike a narrative, SBAR language should be prompt and precise, transmitting only the necessary information to make a decision. In a healthcare situation, SBAR can be applied as follows:
- Situation—Brief and to-the-point explanation of what is happening with the patient
- Background—Clinical background pertinent to the current situation
- Assessment—Clinical impression of the patient
- Recommendation—Suggestions of what action is to be taken
Call-out is a technique to share critical information during an emergency situation. Although information is directed to a specific individual, the entire team can hear it.
Call-back is a closed-loop communication tool that enables the verification and validation of the information exchanged. This tool can be used to confirm verbal orders or to verify that a request has been heard. During a surgery, for example, when the surgeon asks that radiology be called, the circulator nurse could reply that “radiology has been called,” thus closing the loop.
The hand-off is used to enhance information exchanges during transitions of care. Not only is information exchanged on issues such as degree of uncertainty, response to treatment, changes in condition, and treatment plan, but the hand-off also transfers authority and responsibility. Lack of clarity about who is responsible for care and decision making is a major contributor to medical error. The Joint Commission National Patient Safety Goals require facilities to have a standardized approach to hand-offs that includes the opportunity to ask and respond to questions.
Communication is an essential skill to support teamwork and patient safety. Effective communication fosters a culture of mutual support and ensures members have a shared mental model. As with any skill, practice in communicating is imperative.
William J. Richardson, MD, is a member of the AAOS Patient Safety Committee. He can be reached at email@example.com
The Critical Cs
This is the last in a series of AAOS Now articles exploring the six critical components of surgical safety identified by Calvin C. Kuo, MD, and William J Robb III, MD.
Links to the other articles can be found in the online and epub versions available at www.aaosnow.org
The Six Critical Cs include the following:
- Consent—accurate and timely informed surgical consent
- Confirmation—timely and correct identification of the surgical patient, surgical site, and surgical procedure
- Consistency—regular use of standardized, validated, evidence- and/or consensus-based surgical processes such as checklists
- Concentration—focused patient, surgeon, and surgical team interactions without distractions
- Collection—timely and systematic safety data accumulation and analysis
- Communication—effective, transparent patient and surgical team communication
Kohn LT, Corrigan JM, Donaldson MS: To Err is Human: Building a Safer Health System. Washington, DC, National Academies Press, 1999.
- Kuo CC, Robb WJ 3rd: Critical roles of orthopaedic surgeon leadership in healthcare systems to improve orthopaedic surgical patient safety. Clin Orthop Relat Res. 2013;471(6):1792-1800.
- The Joint Commission: Sentinel Event Database. Accessed January 4, 2013.
- James MA, Seiler JG 3rd, Harrast JJ, Emery SE, Hurwitz S: The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery. J Bone Joint Surg Am 2012;94(1):e2(1–12).