We will be performing site maintenance on AAOS.org on February 8th from 7:00 PM – 9:00 PM CST which may cause sitewide downtime. We apologize for the inconvenience.

Courtesy of THINKSTOCK


Published 5/1/2015
James A. Slough, MD

Improving Surgical Safety: Developing a Safety Culture and Checklist Usage

Despite multiple nationwide and global patient safety initiatives (Table 1), surgical and patient safety errors are still common and adverse event rates for surgical conditions remain unacceptably high. Some studies have shown that about one-half of hospital adverse events are associated with surgical procedures conducted in the operating room (OR). Errors involving the wrong site/side/level/implant/procedure/patient still occur, although they are primarily system errors rather than surgeon errors.

The most frequent causes of surgical errors are inadequate or missing surgical information, scheduling discrepancies or errors, irregularities in the preoperative holding process, inadequate or absent surgical site marking, poor communication, distractions in the OR, and inadequate or absent OR process “timeouts.”

Adverse events resulting from surgical interventions are actually more frequently related to errors that occur before or after the procedure than to technical mistakes by a surgical blade “gone wrong.” These errors include the following:

  • a breakdown in communication within and among the surgical team, care providers, patients, and families
  • a delay in diagnosis or failure to diagnose
  • a delay in treatment or failure to treat

On a daily basis, surgeons must respond to challenges that reach far beyond purely technical aspects. For example, the decision to choose observation and/or nonsurgical care must be weighed against the risk of being accused of providing delayed or negligent care. Patient safety in surgery remains a challenge.

Changing a culture
Human factors training and implementation of more standardized surgical checklists have been shown to substantially change the culture of the OR. Human factors training is based on the crew resource management (CRM) programs championed by the airline industry and the National Aeronautics and Space Administration (NASA). Before the implementation of CRM programs, the flight team was often afraid to challenge the captain even in the face of critical errors. A similar situation continues to exist in most ORs today. Staff may find it hard to question decisions made by the surgeon even though the decision may lead to patient harm.

The working environment in both the airline and healthcare industries is characterized by significant on-time pressures, high workloads, dependence on properly working equipment, a rigid hierarchy, and a potential for catastrophic results if errors occur. Effective communication is critical for safety in both industries. Based on the premise that “Good judgment comes from experience, which comes from poor judgment,” NASA’s safety culture originated from lessons learned through system failure analysis after dramatic fatal accidents.

Patient safety in surgery should model on the following five core principles from NASA’s proven safety culture paradigm:

  • reporting culture—reporting concerns without fear of reprisal
  • learning culture—learning from successes and failures
  • flexible culture—changing and adapting to meet new demands
  • engaged culture—everyone doing their part
  • just culture—treating each other fairly

At the core of the human factors training for surgeons is a preoperative briefing by the attending surgeon. This briefing is very similar to the checklists currently being espoused by the World Health Organization (WHO). The preoperative briefing sets expectations as to how the conduct of the case will proceed. It informs the OR staff about the equipment needed and any potential difficulties.

More importantly, the preoperative briefing also opens the lines of communication and helps to break down the hierarchy of the OR. Under conditions of great stress, it is easy to lose situational awareness and become focused on only one aspect of the case. Often other people in the room recognize that an error is being made but are too afraid to speak up. The preoperative briefing should encourage anyone in the room to speak up if an error is being made. Preoperative briefings changes, when implemented, decrease team issues, procedural potential adverse events, equipment issues, patient tissues, and circulator trips out of the room to get equipment.

A postoperative debriefing is also encouraged. This may help resolve equipment issues on a timely basis and address factors contributing to intraoperative delays, resulting in a decrease in the future risk of potential adverse events.

Customized, site-specific, preprocedure checklist briefings should cover the patient status, team members’ roles, the team’s plans, and any potential pitfalls. Checklists should include allergies, site, side, procedure, medical problems impacting care, anticipated blood loss, confirmation of images if applicable, and any equipment concerns or needs.

At their best, checklists function as standardized communication tools promoting information exchange and team cohesion and giving the surgeon the opportunity to conduct a quick team preoperative briefing. One of the reasons surgeons have been slow to implement these changes has been a perception that a briefing would slow down the progress of the case and not enhance their practice or patient care to any measurable amount. In places that have successfully implemented a safety culture initiative, this concern has been shown to be unfounded.

Formal training of a safety culture should include all members of the OR team. Doctors, nurses, and other OR staff should train as a group to help foster a team approach. Team training has been shown to help break down some of the hierarchy present in the OR by making nurses and OR staff more comfortable questioning the physician if they feel that something is going wrong.

The most important lesson learned by organizations that have successfully implemented these changes is that initiatives for cultural change within the OR have to be physician-led. Ideally, a core group of physician champions will lead the change process. Many of the current limitations to the creation of a globally recognized and consistently practiced ‘culture of patient safety’ stem from the lack of surgeon-driven leadership. Transparent leadership and credible role modeling are the prerequisites to ensure unwavering ‘buy-in’ by all members of the healthcare team for adoption of safety practices in the daily routine, including strict adherence to patient safety checklists and safety core measures.

Effective patient and surgical team communication is important with TeamSTEPPS training programs, originally developed by the Agency for Healthcare Research and Quality. Human factors need to support a culture of safety; a distraction-free, focused OR environment; standardized surgical processes (including accurate, timely, patient-centered informed consent and proper marking and confirmation of the site/side/level/implant/procedure/patient using standardized surgical checklists); and systemic surgical data collection and analysis.

Going through the TeamSTEPPS training program can result in many benefits, including the following:

  • better collaboration, coordination, and communication among surgeons, anesthesia providers, nurses, technicians, and patients/families across the continuum of care
  • proactive sharing of accurate information across disciplines and including patients
  • decreased errors such as wrong-site surgery, retained foreign objects, protocol deviations for perioperative antibiotics, staff or patient misunderstandings about optimal postoperative treatment
  • increased patient and staff satisfaction due to enhanced teamwork
  • decreased rates of infections, major complications, morbidity, and mortality
  • decreased barriers to communication; improved quality and safety; decreased malpractice risks
  • improved reputation of orthopaedic surgeons, units, and facilities
  • greater efficiency and effectiveness leading to decreased cost of care

In summary, embracing, encouraging, and instituting a safety culture in your ORs, adding surgical briefings and debriefings, and strictly adhering to surgical checklists should decrease the risk of adverse surgical errors, improve the OR environment, and add value to your practice.

James A. Slough, MD, is a member of the AAOS Medical Liability Committee and a Board of Councilors representative from New York. He can be reached at jslough@excelsiorortho.com

Editor’s note: Articles labeled Orthopaedic Risk Manager (ORM) are presented by the Medical Liability Committee under the direction of Robert R. Slater Jr, MD, ORM editor. Articles are provided for general information and are not legal advice; for legal advice, consult a qualified professional. Email your comments to feedback-orm@aaos.org or contact this issue’s contributors directly.