Elsevier

Surgery

Volume 142, Issue 1, July 2007, Pages 102-110
Surgery

Original communication
Improving patient safety by identifying latent failures in successful operations

https://doi.org/10.1016/j.surg.2007.01.033Get rights and content

Background

The risk of technical failure during operations is recognized, but there is evidence that further improvements in safety depend on systems factors, in particular, effective team skills. The hypotheses that small problems can escalate to more serious situations and that effective teamwork can prevent the development of serious situations, were examined to develop a method to assess these skills and to provide evidence for improvements in training and systems.

Method(s)

Observations were made during 24 pediatric cardiac and 18 orthopedic operations. Operations were classified by accepted indicators of risk and the observations used to generate indicators of performance. Negative events were recorded and organized into 3 levels of clinical importance (minor problems, those negative events that were seemingly innocuous; intraoperative performance, the proportion of key operating tasks that were disrupted; and major problems, events that compromised directly the safety of the patient or the quality of the treatment). The ability of the team to work together safely was classified using a validated scale adapted from research in aviation. Operative duration was also recorded.

Result(s)

Both escalation and teamwork hypotheses were supported. Multiple linear regression suggests that for every 3 minor problems above the 9.9 expected per operation (P <.001), intraoperative performance reduces by 1% (P = .005), and operative duration increases by 10 minutes (P = .032). Effective teams have fewer minor problems per operation (P = .035) and consequently higher intraoperative performance and shorter operating times. Operative risk affected intraoperative performance (P = .004) and duration (P <.001), with the type of operation affecting only duration (P <.001). Eight major problems were observed; these showed a strong association with risk, intraoperative performance, teamwork, and the number of minor problems.

Conclusion(s)

Structured observation of effective teamwork in the operating room can identify substantive deficiencies in the system, even in otherwise successful operations. Decreasing the number of minor problems can lead to a smoother, safer, and shorter operation. Effective teamwork can help decrease the number of small problems and prevent them from escalating to more serious situations. The most effective and sustainable route to improved safety is in capturing these minor problems and identifying related system improvements, combined with training in safe team working. This method is a validated and practical way to improve performance during otherwise successful operations.

Section snippets

Materials and methods

This was a prospective, observational study of intraoperative events in 2 different types of intraoperative care. Pediatric cardiac operation features multiple specialties, close coupling of concurrent tasks, uncertainty, changing plans, and a high workload,13 and was chosen as a model of complex operation.3 Elective orthopedic operation was investigated in another hospital in which the orthopedic operations were high volume, low risk,14 highly proceduralized, and a relatively invariant type of

Results

Forty-two operations were studied: 24 in pediatrics, and 18 in orthopedics. All operations were regarded as having a successful outcome with no 28-day mortality. None of the operations studied were considered to be unusual in terms of the individuals involved, the procedures themselves, or the condition of the patients. Often, the same members of the operating room team were involved, but neither members nor roles were always identical. In orthopedic operation, the first surgeon was always a

Discussion

Our study supports the hypotheses that complications during operations can arise from an escalation of smaller problems and that effective teamwork can mitigate these problems. In this small sample of competent practitioners, it was not a lack of technical knowledge and skills that were the cause of these problems, but the context in which the operation took place. The problems identified in these operations reflected individual errors by members of the team, failures in group processes,

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    Supported in part by the Patient Safety Research Programme, Department of Health, UK.

    1

    T.D. and G.H. are Directors of Atrainability Ltd, which provides non-technical skills training for aviation and healthcare.

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