ORIGINAL ARTICLE
Inadequate Preoperative Team Briefings Lead to More Intraoperative Adverse Events Joideep Phadnis, MBChB, MRCS, Dip Sp & Ex Med, FRCS Tr & Orth and Oliver Templeton-Ward, BMBS, BMedSci, MRCS, FRCS Tr & Orth Introduction: Implementation of the World Health Organization checklists has reduced major surgical complications and errors; however, the impact of preoperative briefings on intraoperative adverse events has not been assessed. Materials and Methods: A prospective case-control study assessing the association between preoperative briefings and minor, potentially major, and major adverse intraoperative events was performed in 2 phases. Phase 1 involved prospective data collection for all trauma and orthopedic lists during a 2-week period. Changes were implemented as a result of the findings, and after this, the study was repeated (phase 2) to assess for the effect of the changes made to the practice. Results: Forty-one lists were audited during phase 1 and 47 lists were audited during phase 2 of the study. Adequate preoperative briefings were performed in 10 (24%) of 41 lists in phase 1. There was a significant association between the occurrences of intraoperative adverse events (n = 37) when a briefing was not performed (P = < 0.01) and when a briefing was performed incompletely (P = 0.01). In phase 2, after staff reeducation and policy change, briefings were found to be adequate in 38 (81%) of 47 lists with the occurrence of only 3 adverse events. Team familiarity also improved significantly as a result of better preoperative briefings (P = 0.02). Conclusions: Inadequate preoperative briefings are associated with an increase in minor adverse events and are detrimental to team familiarity. On the basis of our findings, we recommend that all surgical units perform preoperative briefings thoroughly to minimize these factors. Key Words: surgery, WHO checklist, adverse events (J Patient Saf 2015;00: 00–00)
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n the last few decades, patient safety has come to the forefront of surgical practice with clinicians, health care providers, and the public now more aware of its importance. Leape1 originally highlighted the high incidence of errors within hospitals and the need for a systematic change of attitudes toward patient safety. A drive toward optimizing surgical safety by improving teamwork and using checklists led to the landmark publication of the World Health Organization (WHO) document, Safe Surgery Saves Lives, in 2008.2 The core initiative of this publication was the introduction of the “time-out” checklist, which is now ubiquitous worldwide and has resulted in a reduction in major complications and wrong-site surgery.3 Preoperative team briefings and postoperative debriefings were not part of the initial WHO document, and in subsequent publications, briefings have been recommended but not made mandatory despite the fact that they have been shown to improve teamwork, communication, theater efficiency and foster a better environment for patient safety.4–9 Although sometimes used interchangeably under the umbrella term of “surgical safety checklists,” preoperative briefings are distinct from the WHO From the Royal Surrey County Hospital Guildford, Surrey, United Kingdom. Correspondence: Joideep Phadnis, MBChB, MRCS, Dip Sp & Ex Med, FRCS Tr & Orth, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey GU2 7XX, United Kingdom (e‐mail: [email protected]). The authors disclose no conflict of interest. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Patient Saf • Volume 00, Number 00, Month 2015
time-out, in that they occur once at the beginning of the list, with the aim of improving team communication and highlighting logistical and clinical issues that might occur during the list. The WHO time-out, on the other hand, occurs before the incision for each patient and is designed to prevent wrong-site surgery and major complications. Only in 2010 did the National Patient Safety Agency advise that preoperative briefings (and postoperative debriefings) should be part of a criterion standard “five-step process toward surgical safety.”10 It was the author's observation that in some health care trusts, briefings were performed sporadically, whereas the time-out checklist was in general well adhered to. Hence, the primary aim of this study was to establish whether preoperative briefings were being performed and to what standard they were being performed. The secondary aims were to assess the effect of preoperative briefings on intraoperative adverse events and team familiarity. Our hypothesis was that inadequate briefings might be associated with an increase in minor adverse intraoperative events and be to the detriment of team familiarity. This has not been studied before and is of importance because minor events may not harm the patient per se but disrupt the flow of the list, cause irritation, and have cumulatively been shown to increase the chance of a major event occurring.7
MATERIALS AND METHODS In essence, this was a complete audit cycle measured against the standard that preoperative briefings should be performed before all surgical lists. Phase 1 was a prospective case-control study looking at the incidence of adverse intraoperative events in trauma and orthopedic lists with and without adequate preoperative team briefings. Phase 2 was a repetition of phase 1, after interventions to improve the quality and frequency of preoperative team briefings had been made. The study was performed in a district general hospital with an orthopedic department constituting 12 substantive and 2 locum consultants covering all orthopedic subspecialties including spine, pediatrics, and trauma. All trauma, elective, day case, and main theater lists were included.
Phase 1 During a 2-week period, 41 trauma and orthopedic surgical lists were prospectively audited. The orthopedic registrar designated to be assisting in surgery within each list collected the data. This was performed without the knowledge of any of the other team members and recorded on a standardized electronic form. List demographics including date, consultant in charge, location (main theater or day case unit), duration (half day or full day), and type of list (trauma or elective) were recorded. Further data collection fell into 3 domains as follows: (1) whether a preoperative team briefing was performed completely, incompletely, or not at all; (2) a team familiarity questionnaire; and (3) recording of intraoperative adverse events. Adequacy of preoperative team briefings was classified as “performed completely,” “performed incompletely,” or “not performed.” A complete briefing was defined as one where at a minimum, all key medical (lead surgeon and anesthetist) and nursing staff (most senior staff nurse) were www.journalpatientsafety.com
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Phadnis and Templeton-Ward
present and the briefing included a team introduction and a discussion of the forthcoming list in a systematic manner. An incomplete briefing was one where a briefing was performed but one or more of the criteria mentioned earlier was not met. Briefings were classified as “not performed at all” when no attempt at a formal briefing was made. Team familiarity questions were subjective. The registrars were asked to record if they knew the name and role of all members of the theater team at the beginning of the list and whether by the end of the list this had changed. They were specifically asked not to try and introduce themselves to other team members outside of the team introduction performed as part of the preoperative briefing. If a “complete” briefing had been performed, then it was considered that the registrars knew all team members' names whether they remembered the names by the end of the list. The frequency of adverse events was recorded within the preset categories in the questionnaire and space allowed for a description of the event as well as for recording of events not within the questionnaire. Adverse intraoperative events were defined as an incident at any point during the list that caused disruption or delay to the list or potential or actual patient harm. They were further classified as minor (disrupted the flow of the list but did not harm the patient); potentially major (events that did not harm the patient but, if left unchecked, might have done); and major (an event that harmed the patient). The electronically recorded data were sent to the lead author for collation and analysis.
Interventions Based on the findings of phase 1 (outlined in the Results section), several interventions were implemented to improve performance. These included presentation of the findings at a cross-
speciality meeting, dissemination of the results to the medical director and chief executive, staff education regarding the WHO checklists and how to correctly perform preoperative team briefings, and development of a preoperative briefing template (Fig. 1). It was made clear that this template was for a prelist briefing and that the WHO time-out, performed before “knife to skin” for each patient should be continued as normal. Lastly, a policy change making preoperative briefings mandatory and prevention of sending for the first patient till a briefing was complete was instituted.
Phase 2 In phase 2, a different cohort of registrars were asked to record the data using the same methodology as in phase 1, 6 months after the changes had been implemented. This meant that data collection in phase 2 were completely independent to those in phase 1. Data were collected prospectively for 47 lists during a 2-week period. The emphasis was on determining whether the interventions made had improved the quality of preoperative team briefings and affected the incidence of adverse intraoperative events.
Statistical Analysis Categorical variables and baseline demographic data are described using frequencies and percentages. The difference between groups of categorical variables was analyzed using the w2 test or Fisher exact test when samples were small. The significance of difference between independent proportions was also used to assess the difference between phases 1 and 2. The level of significance was set at P < 0.05. All calculations were performed on IBM SPSS Statistics version 20.0.
FIGURE 1. Preoperative team briefing template developed after phase 1 of the study.
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J Patient Saf • Volume 00, Number 00, Month 2015
Intraoperative Adverse Events
RESULTS Data were collected for 41 lists in phase 1 and 47 lists in phase 2. Table 1 shows the demographics of the lists audited. There was no significant difference between the 2 groups in terms of list demographics.
Phase 1 Preoperative briefings were complete in 10 (24%) of 41 lists, incomplete in 17 (42%) of 41 lists, and not performed at all in 14 (34%) of 41 lists. The most common reason for a briefing being classified as incomplete was the absence of the lead surgeon at the team briefing. Overall, the lead consultant was absent from the briefing in 77% of the lists (Fig. 2). Thirty-seven adverse events were recorded. Thirty-three were classified as minor, and 4 were classified as potentially major. There were no major adverse events. The potentially major events were (1) confusion over the side of surgery once the patient was anesthetized; (2) the wrong patient being sent for and making it to the anesthetic room before being sent back; (3) unavailability of blood products for a major arthroplasty case noted intraoperatively; (4) a patient's head rolled out of the head rest in the beech chair position. The most common type of minor adverse event was equipment-related issues (Fig. 3). Adverse events occurred exclusively in lists where a briefing was either performed incompletely (35% of adverse events) or not performed at all (65% of adverse events). No adverse events occurred in lists where a complete briefing was performed. At least one adverse event was encountered in 6 (35%) of 17 lists with an incomplete briefing and in 12 (86%) of 14 lists without any briefing. There was a statistically higher chance of an adverse event occurring when a briefing was not performed, as compared with when a briefing was performed completely (P ≤ 0.01) or when performed incompletely (P = 0.01). The orthopedic registrar knew all other team members names in 22 (54%) of 41 lists. By the end of the list, this had only improved to 24 (56%) to 41 of the lists. The registrar did not know the anesthetist in 11 cases, the operating department practitioner in 10 cases, and 1 or more of the nursing staff in 13 cases (there were several lists where the registrar did not know the name of >1 other team member).
Phase 2 Preoperative briefings were complete in 38 (81%) of 47 lists, incomplete in 8 (17%) of 47 lists, and not performed in 5 (11%) of 47 of lists. Incomplete briefings were classified as such because of the absence of the lead surgeon in 3 cases, the lead anesthetist in 2 cases, and senior nursing staff in 3 cases. Three minor adverse events were recorded. They were as follows: an equipment
FIGURE 2. Chart showing reason for briefings being classified as incomplete.
issue, a misunderstanding over list order, and unavailability of recovery to transfer the patient out of theater, which delayed the list. Two of these events occurred in 1 list where a briefing was performed but incomplete and 1 event occurred in a list without a briefing. There were no major or potentially major events recorded. Team familiarity had also improved. The registrar knew the name of all other team members at the start of the list in 43 (91%) of 47 cases and by the end of the list in 45 (96%) of 47 cases. In 3 cases, it was the radiographer (not necessarily part of the preoperative briefing) who was not known, and in 1 case, it was the operating department practitioner.
Comparison Between Phases 1 and 2 Figures 3 and 4 illustrate the improvement in quality of preoperative team briefings between the 2 audit phases and the consequent reduction in adverse events as a result of the improved briefings. There was a significant improvement in complete preoperative briefings between phases 1 and 2 (P = 0.03) and a corresponding significant reduction in adverse events between phase 1 and 2 (P ≥ 0.01).
DISCUSSION Worldwide implementation and compliance with the WHO timeout checklist has contributed to a reduction in major complications and wrong-site surgery.3,11 However, fewer studies have specifically assessed the importance of preoperative team briefings. Lingard et al12,13 emphasized the importance of preoperative briefings by demonstrating that they led to a reduction in intraoperative “communication failures” and promoted team communication and cohesion. Defontes14 and Wright15 in separate studies recognized that briefings improved the overall “safety culture” within their
TABLE 1. Comparative Demographics of Audited Lists Expressed Numerically and as Percentages of Total Lists Audited
Elective Trauma Main theater Day stay unit Half-day lists Full-day lists Total lists audited
Initial Audit
Reaudit
31 (76%) 10 (24%) 30 (73%) 11 (27%) 32 (78%) 9 (22%) 41
38 (81%) 9 (19%) 37 (79%) 10 (21%) 36 (77%) 11 (23%) 47
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FIGURE 3. Chart showing whether a preoperative team briefing was performed as a percentage of the total lists audited. www.journalpatientsafety.com
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Phadnis and Templeton-Ward
organization. In a questionnaire study, Khoshbin et al5 found that briefings improved the ability of individuals within a team to speak up about errors and helped staff feel more empowered. Paull et al16 found that there was a significantly higher rate of antibiotic and thromboprophylaxis administration as a result of a preoperative briefing. To our knowledge, other than ours, this is the only study to look directly at the impact of briefings on what happens during the list. Our aim was not to identify major adverse events such as wrong-site surgery. We were not expecting these to occur because adherence to the WHO time-out checklist has thankfully reduced such events to almost negligible. We were keen to look at whether the incidence of minor events was related to briefings. These events in general occur because of lack of organization, inadequate communication, or failure to plan lists properly. They disrupt the flow of the list, cause delays, and lead to irritation, which is counterproductive to team cohesion. Moreover, multiple minor events have been shown to predispose to a major events occurring.7 Our phase 1 results showed a significant association between minor adverse events and inadequate preoperative briefings. When a complete briefing was performed, there were no recorded adverse events. The vast majority of these events were potentially avoidable had an appropriate briefing occurred (Fig. 5). Equipment issues, list order management, and staffing availability problems would all have been flagged in a preoperative brief. In the only other study similar to this, Bandari et al17 audited the number of “potential surgical defects” picked up in briefings and debriefings and found that 46% of “defects” were identified during the briefing, with most being equipment related. We also found that incomplete briefings were associated with more adverse events compared with complete briefings. The most common reason for a briefing to be classified as incomplete was lack of senior clinician attendance (Fig. 2). This implies that it is not only the process of briefing that is important but also the personnel involved. By nature, senior clinicians with more experience are better placed to plan equipment needs, list ordering, and spot potential problems. Nevertheless, not all lists with incomplete briefings had adverse events. Looking more closely, we realized that lists with more senior surgeons, elective lists, and surgeons that performed a narrower spectrum of procedures did not necessarily have adverse events despite briefings being incomplete or not performed. This perhaps shows that briefings are most important in lists where there are a variety of different cases (such as trauma) and/or the lead surgeon is more junior. However, given our overall findings, we would still advocate that all surgeons partake in briefings. Four potentially major adverse events were identified in phase 1. Once more, 3 of these were clearly avoidable had a briefing been performed—wrong
FIGURE 4. Adverse events in relation to whether a briefing was performed completely, incompletely, or not at all.
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J Patient Saf • Volume 00, Number 00, Month 2015
FIGURE 5. Categorization of adverse events.
patient sent for, confusion over side of surgery, and blood not available. The last potential major adverse event was a patient's head rolling out of a head support. This may not have been avoided by the briefing itself but may have been less likely in an environment better promoting teamwork and patient safety, fostered by a preoperative briefing. Phase 1 also highlighted a failure in team familiarity. The registrar auditing the list only knew all other team members names 54% of the time, but more worryingly, this had barely improved during the list, indicating a lack of basic communication between staff during the list. A complete briefing starts with a team introduction, and therefore, this problem would have been nullified had a briefing been performed. This is supported by the findings in phase 2 where briefings were complete 81% of the time and team familiarity was 91% at the start of the list and 96% by the end of the lists. Adverse events in phase 2 were greatly reduced with no major or potentially major events occurring and only 3 minor events in 47 lists. Again, these 3 events occurred in lists without complete briefings and were preventable had an adequate briefing taken place. We were able to achieve improved compliance with briefings by taking several steps. First, the results of phase 1 were presented to a multidisciplinary directorate meeting attended by the chief executive and medical director. This gave the findings clout and allowed them to be disseminated to all levels of staff within the organization. We then developed a briefing template (Fig. 1), which provided a framework for staff to perform briefings, and also introduced a policy that the first patient on the list would not be sent for until a briefing was performed. These changes and the acknowledgment of staff that we were underperforming led to a paradigm change in patient safety culture. We would strongly advocate the use of a briefing checklist as this standardizes briefings to ensure all facets of the list are covered. However, despite the improvements, we did not achieve 100% complete briefings in phase 2. This highlights the difficulties with making change to an organization and that change must be introduced in stages to have maximal effect. The drawbacks of this study are also some of its strengths. Multiple observers collected the data across multiple lists, which may have led to observer bias but allowed coverage of a wide spectrum of trauma and orthopedic lists. Phase 2 data were collected by a different set of observers to phase 1, which again may have led to observer bias but conversely meant that the phase 2 data collection was completely independent of phase 1, adding validity to the results. Last, despite this being a single-center, single-speciality study, performed over a relatively short period, we feel our results are so convincingly in favor of performing adequate preoperative briefings that they warrant wider dissemination. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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J Patient Saf • Volume 00, Number 00, Month 2015
CONCLUSIONS This is the first study to look at the relationship between preoperative briefings and adverse intraoperative events. We found a significant association between adverse events and inadequate briefings and that implementation of change significantly improved the quality of briefings with a corresponding reduction in adverse events. REFERENCES 1. Leape LL. Error in medicine. JAMA. 1994;272:1851–1857. 2. WHO Guidelines for Safe Surgery 2008: Safe Surgery Saves Lives, Geneva, Switzerland: World Health Organization; 2008. 3. Haynes AB, Weiser TG, Berry WR, et al., Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491–499. 4. Bethune R, Sasirekha G, Sahu A, et al. Use of briefings and debriefings as a tool in improving team work, efficiency, and communication in the operating theatre. Postgrad Med J. 2011;87:331–334. 5. Khoshbin A, Lingard L, Wright JG. Evaluation of preoperative and perioperative operating room briefings at the Hospital for Sick Children. Can J Surg. 2009;52:309–315. 6. Ali M, Osborne A, Bethune R, et al. Preoperative surgical briefings do not delay operating room start times and are popular with surgical team members. J Patient Saf. 2011;7:139–143. 7. Skevington SM, Langdon JE, Giddins G. ‘Skating on thin ice?’ Consultant surgeon's contemporary experience of adverse surgical events. Psychol Health Med. 2012;17:1–16.
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Intraoperative Adverse Events
8. Russ S, Rout S, Sevdalis N, et al. Do safety checklists improve teamwork and communication in the operating room? A systematic review. Ann Surg. 2013;258:856–871. 9. Allard J, Bleakley A, Hobbs A, et al. Pre-surgery briefings and safety climate in the operating theatre. BMJ Qual Saf. 2011;20:711–717. 10. National Patient Safety Agency UK. How to Guide: Five Steps to Safer Surgery; 2010. 11. Treadwell JR, Lucas S, Tsou AY. Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Saf. 2014;23:299–318. 12. Lingard L, Espin S, Rubin B, et al. Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR. Qual Saf Health Care. 2005;14:340–346. 13. Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg. 2008;143:12–17. 14. Defontes J. Pre-operative safety briefing project. Perm J. 2004;8:21–27. 15. Wright M. KP northwest preoperative briefing project. Perm J. 2005;9: 35–39. 16. Paull DE, Mazzia LM, Wood SD, et al. Briefing guide study: preoperative briefing and postoperative debriefing checklists in the Veterans Health Administration medical team training program. Am J Surg. 2010; 200:620–623. 17. Bandari J, Schumacher K, Simon M, et al. Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical center. Jt Comm J Qual Patient Saf. 2012; 38:154–160.
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Inadequate Preoperative Team Briefings Lead to More Intraoperative Adverse Events Joideep Phadnis, MBChB, MRCS, Dip Sp & Ex Med, FRCS Tr & Orth and Oliver Templeton-Ward, BMBS, BMedSci, MRCS, FRCS Tr & Orth Introduction: Implementation of the World Health Organization checklists has reduced major surgical complications and errors; however, the impact of preoperative briefings on intraoperative adverse events has not been assessed. Materials and Methods: A prospective case-control study assessing the association between preoperative briefings and minor, potentially major, and major adverse intraoperative events was performed in 2 phases. Phase 1 involved prospective data collection for all trauma and orthopedic lists during a 2-week period. Changes were implemented as a result of the findings, and after this, the study was repeated (phase 2) to assess for the effect of the changes made to the practice. Results: Forty-one lists were audited during phase 1 and 47 lists were audited during phase 2 of the study. Adequate preoperative briefings were performed in 10 (24%) of 41 lists in phase 1. There was a significant association between the occurrences of intraoperative adverse events (n = 37) when a briefing was not performed (P = < 0.01) and when a briefing was performed incompletely (P = 0.01). In phase 2, after staff reeducation and policy change, briefings were found to be adequate in 38 (81%) of 47 lists with the occurrence of only 3 adverse events. Team familiarity also improved significantly as a result of better preoperative briefings (P = 0.02). Conclusions: Inadequate preoperative briefings are associated with an increase in minor adverse events and are detrimental to team familiarity. On the basis of our findings, we recommend that all surgical units perform preoperative briefings thoroughly to minimize these factors. Key Words: surgery, WHO checklist, adverse events (J Patient Saf 2015;00: 00–00)
I
n the last few decades, patient safety has come to the forefront of surgical practice with clinicians, health care providers, and the public now more aware of its importance. Leape1 originally highlighted the high incidence of errors within hospitals and the need for a systematic change of attitudes toward patient safety. A drive toward optimizing surgical safety by improving teamwork and using checklists led to the landmark publication of the World Health Organization (WHO) document, Safe Surgery Saves Lives, in 2008.2 The core initiative of this publication was the introduction of the “time-out” checklist, which is now ubiquitous worldwide and has resulted in a reduction in major complications and wrong-site surgery.3 Preoperative team briefings and postoperative debriefings were not part of the initial WHO document, and in subsequent publications, briefings have been recommended but not made mandatory despite the fact that they have been shown to improve teamwork, communication, theater efficiency and foster a better environment for patient safety.4–9 Although sometimes used interchangeably under the umbrella term of “surgical safety checklists,” preoperative briefings are distinct from the WHO From the Royal Surrey County Hospital Guildford, Surrey, United Kingdom. Correspondence: Joideep Phadnis, MBChB, MRCS, Dip Sp & Ex Med, FRCS Tr & Orth, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey GU2 7XX, United Kingdom (e‐mail: [email protected]). The authors disclose no conflict of interest. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Patient Saf • Volume 00, Number 00, Month 2015
time-out, in that they occur once at the beginning of the list, with the aim of improving team communication and highlighting logistical and clinical issues that might occur during the list. The WHO time-out, on the other hand, occurs before the incision for each patient and is designed to prevent wrong-site surgery and major complications. Only in 2010 did the National Patient Safety Agency advise that preoperative briefings (and postoperative debriefings) should be part of a criterion standard “five-step process toward surgical safety.”10 It was the author's observation that in some health care trusts, briefings were performed sporadically, whereas the time-out checklist was in general well adhered to. Hence, the primary aim of this study was to establish whether preoperative briefings were being performed and to what standard they were being performed. The secondary aims were to assess the effect of preoperative briefings on intraoperative adverse events and team familiarity. Our hypothesis was that inadequate briefings might be associated with an increase in minor adverse intraoperative events and be to the detriment of team familiarity. This has not been studied before and is of importance because minor events may not harm the patient per se but disrupt the flow of the list, cause irritation, and have cumulatively been shown to increase the chance of a major event occurring.7
MATERIALS AND METHODS In essence, this was a complete audit cycle measured against the standard that preoperative briefings should be performed before all surgical lists. Phase 1 was a prospective case-control study looking at the incidence of adverse intraoperative events in trauma and orthopedic lists with and without adequate preoperative team briefings. Phase 2 was a repetition of phase 1, after interventions to improve the quality and frequency of preoperative team briefings had been made. The study was performed in a district general hospital with an orthopedic department constituting 12 substantive and 2 locum consultants covering all orthopedic subspecialties including spine, pediatrics, and trauma. All trauma, elective, day case, and main theater lists were included.
Phase 1 During a 2-week period, 41 trauma and orthopedic surgical lists were prospectively audited. The orthopedic registrar designated to be assisting in surgery within each list collected the data. This was performed without the knowledge of any of the other team members and recorded on a standardized electronic form. List demographics including date, consultant in charge, location (main theater or day case unit), duration (half day or full day), and type of list (trauma or elective) were recorded. Further data collection fell into 3 domains as follows: (1) whether a preoperative team briefing was performed completely, incompletely, or not at all; (2) a team familiarity questionnaire; and (3) recording of intraoperative adverse events. Adequacy of preoperative team briefings was classified as “performed completely,” “performed incompletely,” or “not performed.” A complete briefing was defined as one where at a minimum, all key medical (lead surgeon and anesthetist) and nursing staff (most senior staff nurse) were www.journalpatientsafety.com
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Phadnis and Templeton-Ward
present and the briefing included a team introduction and a discussion of the forthcoming list in a systematic manner. An incomplete briefing was one where a briefing was performed but one or more of the criteria mentioned earlier was not met. Briefings were classified as “not performed at all” when no attempt at a formal briefing was made. Team familiarity questions were subjective. The registrars were asked to record if they knew the name and role of all members of the theater team at the beginning of the list and whether by the end of the list this had changed. They were specifically asked not to try and introduce themselves to other team members outside of the team introduction performed as part of the preoperative briefing. If a “complete” briefing had been performed, then it was considered that the registrars knew all team members' names whether they remembered the names by the end of the list. The frequency of adverse events was recorded within the preset categories in the questionnaire and space allowed for a description of the event as well as for recording of events not within the questionnaire. Adverse intraoperative events were defined as an incident at any point during the list that caused disruption or delay to the list or potential or actual patient harm. They were further classified as minor (disrupted the flow of the list but did not harm the patient); potentially major (events that did not harm the patient but, if left unchecked, might have done); and major (an event that harmed the patient). The electronically recorded data were sent to the lead author for collation and analysis.
Interventions Based on the findings of phase 1 (outlined in the Results section), several interventions were implemented to improve performance. These included presentation of the findings at a cross-
speciality meeting, dissemination of the results to the medical director and chief executive, staff education regarding the WHO checklists and how to correctly perform preoperative team briefings, and development of a preoperative briefing template (Fig. 1). It was made clear that this template was for a prelist briefing and that the WHO time-out, performed before “knife to skin” for each patient should be continued as normal. Lastly, a policy change making preoperative briefings mandatory and prevention of sending for the first patient till a briefing was complete was instituted.
Phase 2 In phase 2, a different cohort of registrars were asked to record the data using the same methodology as in phase 1, 6 months after the changes had been implemented. This meant that data collection in phase 2 were completely independent to those in phase 1. Data were collected prospectively for 47 lists during a 2-week period. The emphasis was on determining whether the interventions made had improved the quality of preoperative team briefings and affected the incidence of adverse intraoperative events.
Statistical Analysis Categorical variables and baseline demographic data are described using frequencies and percentages. The difference between groups of categorical variables was analyzed using the w2 test or Fisher exact test when samples were small. The significance of difference between independent proportions was also used to assess the difference between phases 1 and 2. The level of significance was set at P < 0.05. All calculations were performed on IBM SPSS Statistics version 20.0.
FIGURE 1. Preoperative team briefing template developed after phase 1 of the study.
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J Patient Saf • Volume 00, Number 00, Month 2015
Intraoperative Adverse Events
RESULTS Data were collected for 41 lists in phase 1 and 47 lists in phase 2. Table 1 shows the demographics of the lists audited. There was no significant difference between the 2 groups in terms of list demographics.
Phase 1 Preoperative briefings were complete in 10 (24%) of 41 lists, incomplete in 17 (42%) of 41 lists, and not performed at all in 14 (34%) of 41 lists. The most common reason for a briefing being classified as incomplete was the absence of the lead surgeon at the team briefing. Overall, the lead consultant was absent from the briefing in 77% of the lists (Fig. 2). Thirty-seven adverse events were recorded. Thirty-three were classified as minor, and 4 were classified as potentially major. There were no major adverse events. The potentially major events were (1) confusion over the side of surgery once the patient was anesthetized; (2) the wrong patient being sent for and making it to the anesthetic room before being sent back; (3) unavailability of blood products for a major arthroplasty case noted intraoperatively; (4) a patient's head rolled out of the head rest in the beech chair position. The most common type of minor adverse event was equipment-related issues (Fig. 3). Adverse events occurred exclusively in lists where a briefing was either performed incompletely (35% of adverse events) or not performed at all (65% of adverse events). No adverse events occurred in lists where a complete briefing was performed. At least one adverse event was encountered in 6 (35%) of 17 lists with an incomplete briefing and in 12 (86%) of 14 lists without any briefing. There was a statistically higher chance of an adverse event occurring when a briefing was not performed, as compared with when a briefing was performed completely (P ≤ 0.01) or when performed incompletely (P = 0.01). The orthopedic registrar knew all other team members names in 22 (54%) of 41 lists. By the end of the list, this had only improved to 24 (56%) to 41 of the lists. The registrar did not know the anesthetist in 11 cases, the operating department practitioner in 10 cases, and 1 or more of the nursing staff in 13 cases (there were several lists where the registrar did not know the name of >1 other team member).
Phase 2 Preoperative briefings were complete in 38 (81%) of 47 lists, incomplete in 8 (17%) of 47 lists, and not performed in 5 (11%) of 47 of lists. Incomplete briefings were classified as such because of the absence of the lead surgeon in 3 cases, the lead anesthetist in 2 cases, and senior nursing staff in 3 cases. Three minor adverse events were recorded. They were as follows: an equipment
FIGURE 2. Chart showing reason for briefings being classified as incomplete.
issue, a misunderstanding over list order, and unavailability of recovery to transfer the patient out of theater, which delayed the list. Two of these events occurred in 1 list where a briefing was performed but incomplete and 1 event occurred in a list without a briefing. There were no major or potentially major events recorded. Team familiarity had also improved. The registrar knew the name of all other team members at the start of the list in 43 (91%) of 47 cases and by the end of the list in 45 (96%) of 47 cases. In 3 cases, it was the radiographer (not necessarily part of the preoperative briefing) who was not known, and in 1 case, it was the operating department practitioner.
Comparison Between Phases 1 and 2 Figures 3 and 4 illustrate the improvement in quality of preoperative team briefings between the 2 audit phases and the consequent reduction in adverse events as a result of the improved briefings. There was a significant improvement in complete preoperative briefings between phases 1 and 2 (P = 0.03) and a corresponding significant reduction in adverse events between phase 1 and 2 (P ≥ 0.01).
DISCUSSION Worldwide implementation and compliance with the WHO timeout checklist has contributed to a reduction in major complications and wrong-site surgery.3,11 However, fewer studies have specifically assessed the importance of preoperative team briefings. Lingard et al12,13 emphasized the importance of preoperative briefings by demonstrating that they led to a reduction in intraoperative “communication failures” and promoted team communication and cohesion. Defontes14 and Wright15 in separate studies recognized that briefings improved the overall “safety culture” within their
TABLE 1. Comparative Demographics of Audited Lists Expressed Numerically and as Percentages of Total Lists Audited
Elective Trauma Main theater Day stay unit Half-day lists Full-day lists Total lists audited
Initial Audit
Reaudit
31 (76%) 10 (24%) 30 (73%) 11 (27%) 32 (78%) 9 (22%) 41
38 (81%) 9 (19%) 37 (79%) 10 (21%) 36 (77%) 11 (23%) 47
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FIGURE 3. Chart showing whether a preoperative team briefing was performed as a percentage of the total lists audited. www.journalpatientsafety.com
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organization. In a questionnaire study, Khoshbin et al5 found that briefings improved the ability of individuals within a team to speak up about errors and helped staff feel more empowered. Paull et al16 found that there was a significantly higher rate of antibiotic and thromboprophylaxis administration as a result of a preoperative briefing. To our knowledge, other than ours, this is the only study to look directly at the impact of briefings on what happens during the list. Our aim was not to identify major adverse events such as wrong-site surgery. We were not expecting these to occur because adherence to the WHO time-out checklist has thankfully reduced such events to almost negligible. We were keen to look at whether the incidence of minor events was related to briefings. These events in general occur because of lack of organization, inadequate communication, or failure to plan lists properly. They disrupt the flow of the list, cause delays, and lead to irritation, which is counterproductive to team cohesion. Moreover, multiple minor events have been shown to predispose to a major events occurring.7 Our phase 1 results showed a significant association between minor adverse events and inadequate preoperative briefings. When a complete briefing was performed, there were no recorded adverse events. The vast majority of these events were potentially avoidable had an appropriate briefing occurred (Fig. 5). Equipment issues, list order management, and staffing availability problems would all have been flagged in a preoperative brief. In the only other study similar to this, Bandari et al17 audited the number of “potential surgical defects” picked up in briefings and debriefings and found that 46% of “defects” were identified during the briefing, with most being equipment related. We also found that incomplete briefings were associated with more adverse events compared with complete briefings. The most common reason for a briefing to be classified as incomplete was lack of senior clinician attendance (Fig. 2). This implies that it is not only the process of briefing that is important but also the personnel involved. By nature, senior clinicians with more experience are better placed to plan equipment needs, list ordering, and spot potential problems. Nevertheless, not all lists with incomplete briefings had adverse events. Looking more closely, we realized that lists with more senior surgeons, elective lists, and surgeons that performed a narrower spectrum of procedures did not necessarily have adverse events despite briefings being incomplete or not performed. This perhaps shows that briefings are most important in lists where there are a variety of different cases (such as trauma) and/or the lead surgeon is more junior. However, given our overall findings, we would still advocate that all surgeons partake in briefings. Four potentially major adverse events were identified in phase 1. Once more, 3 of these were clearly avoidable had a briefing been performed—wrong
FIGURE 4. Adverse events in relation to whether a briefing was performed completely, incompletely, or not at all.
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J Patient Saf • Volume 00, Number 00, Month 2015
FIGURE 5. Categorization of adverse events.
patient sent for, confusion over side of surgery, and blood not available. The last potential major adverse event was a patient's head rolling out of a head support. This may not have been avoided by the briefing itself but may have been less likely in an environment better promoting teamwork and patient safety, fostered by a preoperative briefing. Phase 1 also highlighted a failure in team familiarity. The registrar auditing the list only knew all other team members names 54% of the time, but more worryingly, this had barely improved during the list, indicating a lack of basic communication between staff during the list. A complete briefing starts with a team introduction, and therefore, this problem would have been nullified had a briefing been performed. This is supported by the findings in phase 2 where briefings were complete 81% of the time and team familiarity was 91% at the start of the list and 96% by the end of the lists. Adverse events in phase 2 were greatly reduced with no major or potentially major events occurring and only 3 minor events in 47 lists. Again, these 3 events occurred in lists without complete briefings and were preventable had an adequate briefing taken place. We were able to achieve improved compliance with briefings by taking several steps. First, the results of phase 1 were presented to a multidisciplinary directorate meeting attended by the chief executive and medical director. This gave the findings clout and allowed them to be disseminated to all levels of staff within the organization. We then developed a briefing template (Fig. 1), which provided a framework for staff to perform briefings, and also introduced a policy that the first patient on the list would not be sent for until a briefing was performed. These changes and the acknowledgment of staff that we were underperforming led to a paradigm change in patient safety culture. We would strongly advocate the use of a briefing checklist as this standardizes briefings to ensure all facets of the list are covered. However, despite the improvements, we did not achieve 100% complete briefings in phase 2. This highlights the difficulties with making change to an organization and that change must be introduced in stages to have maximal effect. The drawbacks of this study are also some of its strengths. Multiple observers collected the data across multiple lists, which may have led to observer bias but allowed coverage of a wide spectrum of trauma and orthopedic lists. Phase 2 data were collected by a different set of observers to phase 1, which again may have led to observer bias but conversely meant that the phase 2 data collection was completely independent of phase 1, adding validity to the results. Last, despite this being a single-center, single-speciality study, performed over a relatively short period, we feel our results are so convincingly in favor of performing adequate preoperative briefings that they warrant wider dissemination. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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CONCLUSIONS This is the first study to look at the relationship between preoperative briefings and adverse intraoperative events. We found a significant association between adverse events and inadequate briefings and that implementation of change significantly improved the quality of briefings with a corresponding reduction in adverse events. REFERENCES 1. Leape LL. Error in medicine. JAMA. 1994;272:1851–1857. 2. WHO Guidelines for Safe Surgery 2008: Safe Surgery Saves Lives, Geneva, Switzerland: World Health Organization; 2008. 3. Haynes AB, Weiser TG, Berry WR, et al., Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491–499. 4. Bethune R, Sasirekha G, Sahu A, et al. Use of briefings and debriefings as a tool in improving team work, efficiency, and communication in the operating theatre. Postgrad Med J. 2011;87:331–334. 5. Khoshbin A, Lingard L, Wright JG. Evaluation of preoperative and perioperative operating room briefings at the Hospital for Sick Children. Can J Surg. 2009;52:309–315. 6. Ali M, Osborne A, Bethune R, et al. Preoperative surgical briefings do not delay operating room start times and are popular with surgical team members. J Patient Saf. 2011;7:139–143. 7. Skevington SM, Langdon JE, Giddins G. ‘Skating on thin ice?’ Consultant surgeon's contemporary experience of adverse surgical events. Psychol Health Med. 2012;17:1–16.
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Intraoperative Adverse Events
8. Russ S, Rout S, Sevdalis N, et al. Do safety checklists improve teamwork and communication in the operating room? A systematic review. Ann Surg. 2013;258:856–871. 9. Allard J, Bleakley A, Hobbs A, et al. Pre-surgery briefings and safety climate in the operating theatre. BMJ Qual Saf. 2011;20:711–717. 10. National Patient Safety Agency UK. How to Guide: Five Steps to Safer Surgery; 2010. 11. Treadwell JR, Lucas S, Tsou AY. Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Saf. 2014;23:299–318. 12. Lingard L, Espin S, Rubin B, et al. Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR. Qual Saf Health Care. 2005;14:340–346. 13. Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg. 2008;143:12–17. 14. Defontes J. Pre-operative safety briefing project. Perm J. 2004;8:21–27. 15. Wright M. KP northwest preoperative briefing project. Perm J. 2005;9: 35–39. 16. Paull DE, Mazzia LM, Wood SD, et al. Briefing guide study: preoperative briefing and postoperative debriefing checklists in the Veterans Health Administration medical team training program. Am J Surg. 2010; 200:620–623. 17. Bandari J, Schumacher K, Simon M, et al. Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical center. Jt Comm J Qual Patient Saf. 2012; 38:154–160.
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