Pre-op safety briefings help reduce errors, improve care

Health care giant Kaiser Permanente is introducing the idea of a "preoperative safety briefing" to all of its facilities with the aim of encouraging more communication among surgical team members. Kaiser's preliminary experience with the concept suggests that the technique can help reduce adverse events, including sentinel events such as wrong-site surgery, and aid team members in preparing for contingencies during the procedure.

The preoperative safety briefing was modeled on a similar strategy used in the airline industry, explains Douglas Bonacum, MBA, vice president of safety management with Kaiser Permanente in Oakland, CA. Commercial pilots routinely go through a checklist and discuss the upcoming flight before the plane ever leaves the ground, he says, and now Kaiser wants operating teams to do the same thing before a scalpel ever touches skin.

A six-month trial of the system was so successful at Kaiser's Anaheim Medical Center in California that it is being implemented in all of the company's 30 hospitals across the country. The preoperative safety briefing pilot began in February 2002, and six months later the statistics showed that it had improved care at the Anaheim facility. The hospital went from three wrong-site surgeries in the year before the trial to zero during the trial period, Bonacum says.

The new system also has a positive impact on employee morale and perception of the hospital's overall safety, he says. During Anaheim's trial, employee surveys found there were a 19% increase in employee satisfaction and a 16% decrease in nurse turnover. Additionally, most employees' perceptions of the safety climate in the operating room increased from "good" to "outstanding" after implementation of the pilot.

During the trial, the operative teams caught a number of near-misses because of improved communication, says James DeFontes, MD, a Kaiser anesthesiologist who developed the preoperative safety briefings. Those near misses include missing blood products and instruments.

The preoperative safety briefing is an opportunity for all members of the surgical team to have a conversation about the upcoming surgery, reports Bonacum . Everyone in the room — the surgeon, anesthesiologist, scrub nurse, techs, anyone participating in the procedure — should participate.

"It's a time to share information that may be relevant to their teammates prior to surgery, a time to make sure everyone is on the same page," Bonacum says. This differs somewhat from the historical way of doing things in the operating room, which is to assume that each person is a subject matter expert and knows what they need to know for this surgery, he says. "That can still be true, but this method encourages them to share that information with others and see how that exchange might be useful," Bonacum says.

In introducing the idea to hospital staff and physicians, Kaiser used the analogy of an airline cockpit and pointed out that most of us have seen the pilots going through a checklist as we boarded a plane. Wouldn't that same level of communication be good for the operating room, DeFontes asked. And don't you all have some knowledge that could be useful to others?

Examples of the useful exchanges include the anesthesiologist who volunteers that there are certain risks to the patient's airway during this surgery and that the patient is considered high risk by the anesthesiologist even if he is not by the surgeon. That could lead to a discussion of how the team, together, can best manage that risk. Similarly, the surgeon may offer an overview of the exact technique he or she will use, what problems the patient has previously has in surgery, and any particular needs during the procedure.

"That's an opportunity for everyone else to realize that they may need to have a particular instrument or supplies ready, or be ready to respond to certain outcomes," Bonacum says. "They can spot supplies or additional staff they didn't realize they needed, and they can mentally prepare contingency plans."

DeFontes says preoperative briefings help everyone in the room function more as a team rather than individual experts. The culture of many surgery departments is such that people don't come together as a team until the first incision is made, and by then it's a little late for some information to be useful, he says.

"It's a chance for people to verbalize those little things that are on their minds," DeFontes says. "You said you wouldn't need blood, but are you sure? Is this procedure going to be an hour or hour and a half? Do you want the patient awake after surgery or asleep through the night?"

The briefing might include broad statements, such as the surgeon saying he is anxious about the procedure and concerned about the outcome. While not specific, that statement puts people on alert, DeFontes says. The briefings also help unify a team when the members have not worked together before and don't know each other's habits, preferences, and needs.

Kaiser provides a checklist of suggested questions for key team members but doesn't require that they do down the list and discuss each item. They questions are used more as a prompt for any issues that may be pertinent in the surgery at hand, Bonacum says. (Click here for an educational flier from Kaiser that includes the suggested questions.)

Hospitals educate staff and physicians with a short classroom session and role-playing exercises, Bonacum says. The role playing is important because the discussions in a briefing don't come naturally to all team members, he says. The time away from work for the education sessions, usually no more than an hour per person, are the only expense in implementing the system.

Sources

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