Patient Safety and Quality

Studies examine the safety climate and teamwork in hospital operating rooms

Medical errors in the operating room (OR), such as wrong-site or wrong-procedure surgeries, retained sponges in the body, unchecked blood transfusions, and mismatched organ transplants, can be catastrophic. Not surprisingly, a growing number of hospitals are developing patient safety initiatives aimed at creating a safe OR culture. In fact, the Joint Commission on Accreditation of Healthcare Organizations is proposing a requirement that all hospitals routinely measure their safety culture beginning in 2007.

The safety climate in surgical departments varies widely among hospitals, according to a new study. This climate can be validly measured, serving as a benchmark for hospitals to gauge their safety performance. A second study reveals that staff disagree about the level of teamwork in the OR, a critical safety element. Both studies were based on a survey of OR personnel at 60 hospitals in a health system in 16 States. The studies, supported by the Agency for Healthcare Research and Quality (HS14246 and HS11544) and conducted by Johns Hopkins University investigators, are briefly discussed here.

Makary, M.A., Sexton, J.B., Freischlag, J.A., and others (2006, May). "Patient safety in surgery." Annals of Surgery 243(5), pp. 628-635.

This survey of 2,135 OR medical personnel at 60 hospitals in 16 States revealed that the OR safety climate varied greatly among hospitals. The research team developed a surgery-specific Safety Attitudes Questionnaire (SAQ), which demonstrated high face validity and internal consistency. The SAQ measured six domains of safety: teamwork climate, safety climate, job satisfaction, perceptions of management, stress recognition, and working conditions. The researchers calculated the average of seven safety climate scale scores of the validated survey to obtain provider ratings of the OR safety climate.

Three scale items asked if OR personnel were encouraged to report patient safety concerns, whether the culture made it easy to learn from others' mistakes, and whether medical errors were handled appropriately. The four other scale items asked whether individuals knew the proper channels to direct safety questions was received, whether they received appropriate feedback about performance, whether they would feel safe being treated there as a patient, and whether it was difficult to discuss mistakes.

The percentage of frontline providers reporting a good safety climate ranged from about 45 percent for surgical technicians to about 55 percent among staff surgeons. However, scores varied widely among hospitals. The percentage of OR personnel who reported a good safety climate in each hospital ranged from 16.3 to 100 percent. The researchers conclude that OR safety culture can be measured using the safety climate scale of the SAQ.

Makary, M.A., Sexton, J.B., Freischlag, J.A., and others (2006, May). "Operating room teamwork among physicians and nurses: Teamwork in the eye of the beholder." Journal of the American College of Surgeons 202, pp. 746-752.

While OR personnel agree about the safety climate of the OR, they disagree about the level of teamwork in the OR, which is a critical component of patient safety. Nurses and doctors have quite different views, according to this survey of OR personnel at 60 hospitals. The researchers used the SAQ to rate their own peers and each other using a 5-point Likert scale (1 equal to very low and 5 equal to very high).

Ratings of teamwork (collaboration and communication) differed substantially by OR caregiver type. Surgeons rated the teamwork of other surgeons high or very high 85 percent of the time. Similarly, anesthesiologists rated teamwork among anesthesiologists very high and certified registered nurse anesthetists (CRNAs) rated other CRNAs very well (scores were 95.8 and 92.7 percent, respectively). In fact, surgeons perceived that everyone in the OR was doing a good job in terms of teamwork, yet nurses rated their collaboration with surgeons high or very high only 48 percent of the time.

Post-survey feedback discussion revealed that nurses often describe good collaboration as having their input respected. In contrast, physicians often describe it as having nurses who anticipate their needs and follow instructions. The traditional hierarchy of surgery has discouraged nurses from speaking up to surgeons, whom nurses often perceive as unapproachable.

Each member of the OR team should be encouraged to raise issues that could lead to patient harm, suggest the researchers. They recommend the use of presurgical briefings and postoperative debriefings, a method adopted at Johns Hopkins Hospital. Briefings are led by a well-respected surgeon to promote communication through improved teamwork.

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