- Email: [email protected]
The Human Factor and Safety Attitudes in Neurosurgical Operating Rooms
Perspectives Commentary on: Impact of the Time-Out Process on Safety Attitude in a Tertiary Neurosurgical Department by McLaughlin et al. World Neurosurg 2013 http://dx.doi.org/10.1016/j.wneu.2013.07.074
Abdulrazag M. Ajlan, M.B.B.S. Clinical Instructor, Department of Neurosurgery Stanford Hospitals and Clinics Stanford University
The Human Factor and Safety Attitudes in Neurosurgical Operating Rooms Abdulrazag M. Ajlan and Griffith R. Harsh, IV
I
n October 2012, the world watched Austrian skydiver Felix Baumgartner’s free fall jump from a vertical distance of 36,402.6 m. This jump, heralded as a jump from the “edge of space” broke multiple Fe´de´ration Ae´ronautique Internationale, records. It was clear to all that the success of such a complicated task depended on organization and teamwork. During the event, Baumgartner and his team repeatedly reviewed checklists guiding each step. Each checklist item was sequentially noted and faithfully completed in an effort to eliminate all preventable error. Recently, Atul Gawande in his book, The Checklist Manifesto (8), emphasized the utility of checklists in ensuring safe medical practice.
At least one million inpatient preventable medical errors occurred in 2009 in the United States (3). Such errors cost the health care system more than $1 billion every year (3). In 1999, the Institute of Medicine’s report, “To Err Is Human: building a safer health system” estimated that medical errors cause between 44,000 and 98,000 deaths in American hospitals annually (10). It is important, but sometimes difficult, to distinguish between an unavoidable complication and an unnecessary error. Medical error can be defined as the failure of a planned action to be completed as intended or the use of an ill-advised plan to achieve an aim (10). The frequency of such medical errors is likely underestimated because of inadequate reporting (3, 7). In the past decade, health care providers and the public in general have become more aware of medical errors and their adverse effects on the quality and cost of care (1). Data obtained from 56 countries estimated an annual volume of 234 million major surgical procedures worldwide (16). The frequency of reported major inpatient surgical complications in
Key words Leadership - Neurosurgery - Safety attitude - Teamwork - Time-out -
Abbreviations and Acronyms OR: Operating room
WORLD NEUROSURGERY - [-]: ---, MONTH 2013
developed countries ranges between 3% and 22%. Nearly half of these adverse events were determined to be preventable (17). In 2005, the WHO safety program, was launched to facilitate the development and implementation of patient safety policy with the goal of adhering to the principle, “First, do no harm.” Safe surgical care is a major focus of the program. The program advocates use of a surgical safety checklist to reduce preventable errors caused by human factors (13, 17). A checklist was created for each of three points in an operation: 1) sign-in (before anesthesia); 2) time-out (before the surgical incision); and 3) signout (at the end of the procedure). Recent studies have shown that implementation of such checklists has been accompanied by a reduction in surgical complications and deaths in numerous countries, including those with high standards of care (4, 9). Checklists also prepare the surgical team to deal with expected complications. Literature concerning neurosurgical use of checklists, including the time-out, is limited (14). The potential benefits of checklists in preventing major, but rare, adverse events and in improving the safety attitude in the neurosurgical operative room (OR) needs further analysis (2, 12, l4). McLaughlin et al. (15) assessed the impact of the time-out process on health care provider’s safety attitudes and general interaction in the OR. An online survey was distributed to all staff members of the neurosurgery operative room at the Ronald Reagan University of California, Los Angeles Medical Center, including attendings and residents from the neurosurgery and anesthesia departments, circulating nurses, scrub technicians, and neuromonitoring technicians. Most questions sought responses rating degree of concurrence: “strongly agree,” “agree,” “disagree,” and “strongly disagree.” The questionnaire
Department of Neurosurgery, Stanford Hospitals and Clinics, Stanford University, Stanford, California, USA To whom correspondence should be addressed: Abdulrazag M. Ajlan, M.B.B.S. [E-mail: [email protected]] Citation: World Neurosurg. (2013). http://dx.doi.org/10.1016/j.wneu.2013.08.039
www.WORLDNEUROSURGERY.org
1
PERSPECTIVES
was formulated by modifying the Safety Attitude Questionnaire and the Hospital Survey on Patient Safety Culture, two validated measures of patient safety culture (5). The survey was completed by 93 of 128 members. Not surprisingly, 98.9% believed that the time-out process improves patient safety. The strength of agreement varied between neurosurgery and anesthesia members (79.1% and 70.3%, respectively, strongly agreed) and nurses and technicians who answered (96.4%, strongly agreed). Among many factors explored, leadership and teamwork training were identified as major elements with potential for further improvement. Reinforcing the importance of leadership in the OR, there was unanimous agreement that attending surgeons should be present during the time-out, and 76.3% believed that the attending surgeon should lead the time-out. All nurses and technicians strongly agreed that the attending surgeon should be present during the time-out compared with 81.1% and 76.9% of the neurosurgery attendings and residents, respectively. Although time-out brings the full team together physically, the survey indicated that this does not necessarily reinforce a teamwork mentality. All participants believed that the attending surgeon’s preview of anticipated critical elements of the case was helpful. Interestingly, 97% of respondents believed that they learned something new about the patient and/or the procedure during the time-out. This supports the contention that proactively improving awareness of critical concerns can help reduce preventable morbidity. Another interesting finding was that only 15.4% of neurosurgery resident and 16.7% of anesthesia attendings strongly agreed that performing the time-out helps ensure that all team members are comfortable in voicing safety concerns during the case. The authors offer little evidence for their contention that “Surgeons have been known to be independent thinkers, confident in their decisions, and relatively unwelcoming of challenges to judgment”. This study is an important contribution highlighting the positive impact of the time-out process on the safety attitudes and
REFERENCES 1. Brennan TA: The Institute of Medicine report on medical errors—could it do harm? N Engl J Med 342:1123-1125, 2000. 2. Connolly PJ, Kilpatrick M, Jaggi JL, Church E, Baltuch GH: Feasibility of an operational standardized checklist for movement disorder surgery. A pilot study. Stereotact Funct Neurosurg 87: 94-100, 2009. 3. David G, Gunnarsson CL, Waters HC, Horblyuk R, Kaplan HS: Economic measurement of medical errors using a hospital claims database. Value Health 16:305-310, 2013. 4. De Vries EN, Prins HA, Crolla RM, den Outer AJ, van Andel G, van Helden SH, Schlack WS, van Putten MA, Gouma DJ, Dijkgraaf MG, Smorenburg SM, Boermeester MA: Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med 363:1928-1937, 2010.
2
www.SCIENCEDIRECT.com
climate in neurosurgical ORs. McLaughlin et al. appropriately note that one limitation of this study is that the modified survey used has not been validated. Some variability in the “strength” of agreement was observed between the departments and within the same department depending on the level of training, but overall, the answers and degree of agreement were quite similar between groups. The study simply samples opinions and attitudes and does not compare these with and without an intervention, such as adoption of checklists. In addition, it does not attempt to establish a correlation between the safety attitudes and practices, including use of time-out, and a decrease in postoperative complications and mortality. This correlation has proven difficult to establish because of the low numbers of reported major preventable events from a single institution and the difficulty of aggregating results from multiple institutions using different safety protocols and reporting systems (9). Traditionally, knowledge and surgical skills have been considered to be the major elements of surgical training. More recently, the importance of nonsurgical skills, such as teamwork, interpersonal communication, leadership, and decision making, to patient safety outside and inside the ORs is being recognized (18). Globally, training programs are increasingly including some of these elements in their curriculum and its objectives. An excellent example is the CanMEDS Physician Competency Framework developed by the Royal College of Physicians and Surgeons of Canada. The seven roles of heath care providers identified by the CanMEDS educational framework are medical expert, communicator, collaborator, manager, health advocate, scholar, and professional. This model has been applied in many countries to health care and other professionals (6, 11). Adverse events have been estimated to affect 3%e16% of all hospitalized patients, and more than half of such events are thought to be preventable (17). An important initial step in prevention is to increase awareness among the health care providers of the impact of preventable errors on patients care. Faithful adherence to checklist and time-out protocols will enhance the safety attitudes in neurosurgical ORs and reduce the harm caused by adverse events.
5. Etchegaray JM, Thomas EJ: Comparing two safety culture surveys: safety attitudes questionnaire and hospital survey on patient safety. BMJ Qual Saf 21: 490-498, 2012. 6. Frank JR, Danoff D: The CanMEDS initiative: implementing an outcomes-based framework of physician competencies. Med Teach 29:642-647, 2007. 7. Fuller RL, McCullough EC, Bao MZ, Averill RF: Estimating the costs of potentially preventable hospital acquired complications. Health Care Financ Rev 30:17-32, 2009. 8. Gawande A: The checklist manifesto: how to get things right. New York, NY: Metropolitan Books; 2009. 9. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA: A surgical safety checklist to reduce morbidity and mortality
in a global population. N Engl J Med 360:491-499, 2009. 10. Kohn LT, Corrigan J, Donaldson MS: To err is human: building a safer health system. Washington, DC: National Academy Press; 2000. 11. Koo J, Bains J, Collins MB, Dharamsi S: Residency research requirements and the CanMEDS-FM scholar role: perspectives of residents and recent graduates. Can Fam Physician 58:e330-e336, 2012. 12. Lyons MK: Eight-year experience with a neurosurgical checklist. Am J Med Qual 25:285-288, 2010. 13. Mahajan RP: The WHO surgical checklist. Best Pract Res Clin Anaesthesiol 25:161-168, 2011. 14. McConnell DJ, Fargen KM, Mocco J: Surgical checklists: a detailed review of their emergence, development, and relevance to neurosurgical practice. Surg Neurol Int 3:2, 2012.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2013.08.039
PERSPECTIVES
15. McLaughlin N, Winograd D, Chung HR, van de Wiele B, Martin NA: Impact of the time-out process in a tertiary neurosurgical department on safety attitude. World Neurosurg 2013 Jul 25 [Epub ahead of print].
17. WHO: Guidelines for safe surgery, safe surgery saves lives, 2009. Available at: http://whqlibdoc. who.int/publications/2009/9789241598552_eng.pdf. Accessed November 20, 2013.
16. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA: An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 372:139-144, 2008.
18. Yule S, Flin R, Paterson-Brown S, Maran N: Nontechnical skills for surgeons in the operating room: a review of the literature. Surgery 139:140-149, 2006.
Citation: World Neurosurg. (2013). http://dx.doi.org/10.1016/j.wneu.2013.08.039 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com
WORLD NEUROSURGERY - [-]: ---, MONTH 2013
1878-8750/$ - see front matter ª 2013 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org
3
Abdulrazag M. Ajlan, M.B.B.S. Clinical Instructor, Department of Neurosurgery Stanford Hospitals and Clinics Stanford University
The Human Factor and Safety Attitudes in Neurosurgical Operating Rooms Abdulrazag M. Ajlan and Griffith R. Harsh, IV
I
n October 2012, the world watched Austrian skydiver Felix Baumgartner’s free fall jump from a vertical distance of 36,402.6 m. This jump, heralded as a jump from the “edge of space” broke multiple Fe´de´ration Ae´ronautique Internationale, records. It was clear to all that the success of such a complicated task depended on organization and teamwork. During the event, Baumgartner and his team repeatedly reviewed checklists guiding each step. Each checklist item was sequentially noted and faithfully completed in an effort to eliminate all preventable error. Recently, Atul Gawande in his book, The Checklist Manifesto (8), emphasized the utility of checklists in ensuring safe medical practice.
At least one million inpatient preventable medical errors occurred in 2009 in the United States (3). Such errors cost the health care system more than $1 billion every year (3). In 1999, the Institute of Medicine’s report, “To Err Is Human: building a safer health system” estimated that medical errors cause between 44,000 and 98,000 deaths in American hospitals annually (10). It is important, but sometimes difficult, to distinguish between an unavoidable complication and an unnecessary error. Medical error can be defined as the failure of a planned action to be completed as intended or the use of an ill-advised plan to achieve an aim (10). The frequency of such medical errors is likely underestimated because of inadequate reporting (3, 7). In the past decade, health care providers and the public in general have become more aware of medical errors and their adverse effects on the quality and cost of care (1). Data obtained from 56 countries estimated an annual volume of 234 million major surgical procedures worldwide (16). The frequency of reported major inpatient surgical complications in
Key words Leadership - Neurosurgery - Safety attitude - Teamwork - Time-out -
Abbreviations and Acronyms OR: Operating room
WORLD NEUROSURGERY - [-]: ---, MONTH 2013
developed countries ranges between 3% and 22%. Nearly half of these adverse events were determined to be preventable (17). In 2005, the WHO safety program, was launched to facilitate the development and implementation of patient safety policy with the goal of adhering to the principle, “First, do no harm.” Safe surgical care is a major focus of the program. The program advocates use of a surgical safety checklist to reduce preventable errors caused by human factors (13, 17). A checklist was created for each of three points in an operation: 1) sign-in (before anesthesia); 2) time-out (before the surgical incision); and 3) signout (at the end of the procedure). Recent studies have shown that implementation of such checklists has been accompanied by a reduction in surgical complications and deaths in numerous countries, including those with high standards of care (4, 9). Checklists also prepare the surgical team to deal with expected complications. Literature concerning neurosurgical use of checklists, including the time-out, is limited (14). The potential benefits of checklists in preventing major, but rare, adverse events and in improving the safety attitude in the neurosurgical operative room (OR) needs further analysis (2, 12, l4). McLaughlin et al. (15) assessed the impact of the time-out process on health care provider’s safety attitudes and general interaction in the OR. An online survey was distributed to all staff members of the neurosurgery operative room at the Ronald Reagan University of California, Los Angeles Medical Center, including attendings and residents from the neurosurgery and anesthesia departments, circulating nurses, scrub technicians, and neuromonitoring technicians. Most questions sought responses rating degree of concurrence: “strongly agree,” “agree,” “disagree,” and “strongly disagree.” The questionnaire
Department of Neurosurgery, Stanford Hospitals and Clinics, Stanford University, Stanford, California, USA To whom correspondence should be addressed: Abdulrazag M. Ajlan, M.B.B.S. [E-mail: [email protected]] Citation: World Neurosurg. (2013). http://dx.doi.org/10.1016/j.wneu.2013.08.039
www.WORLDNEUROSURGERY.org
1
PERSPECTIVES
was formulated by modifying the Safety Attitude Questionnaire and the Hospital Survey on Patient Safety Culture, two validated measures of patient safety culture (5). The survey was completed by 93 of 128 members. Not surprisingly, 98.9% believed that the time-out process improves patient safety. The strength of agreement varied between neurosurgery and anesthesia members (79.1% and 70.3%, respectively, strongly agreed) and nurses and technicians who answered (96.4%, strongly agreed). Among many factors explored, leadership and teamwork training were identified as major elements with potential for further improvement. Reinforcing the importance of leadership in the OR, there was unanimous agreement that attending surgeons should be present during the time-out, and 76.3% believed that the attending surgeon should lead the time-out. All nurses and technicians strongly agreed that the attending surgeon should be present during the time-out compared with 81.1% and 76.9% of the neurosurgery attendings and residents, respectively. Although time-out brings the full team together physically, the survey indicated that this does not necessarily reinforce a teamwork mentality. All participants believed that the attending surgeon’s preview of anticipated critical elements of the case was helpful. Interestingly, 97% of respondents believed that they learned something new about the patient and/or the procedure during the time-out. This supports the contention that proactively improving awareness of critical concerns can help reduce preventable morbidity. Another interesting finding was that only 15.4% of neurosurgery resident and 16.7% of anesthesia attendings strongly agreed that performing the time-out helps ensure that all team members are comfortable in voicing safety concerns during the case. The authors offer little evidence for their contention that “Surgeons have been known to be independent thinkers, confident in their decisions, and relatively unwelcoming of challenges to judgment”. This study is an important contribution highlighting the positive impact of the time-out process on the safety attitudes and
REFERENCES 1. Brennan TA: The Institute of Medicine report on medical errors—could it do harm? N Engl J Med 342:1123-1125, 2000. 2. Connolly PJ, Kilpatrick M, Jaggi JL, Church E, Baltuch GH: Feasibility of an operational standardized checklist for movement disorder surgery. A pilot study. Stereotact Funct Neurosurg 87: 94-100, 2009. 3. David G, Gunnarsson CL, Waters HC, Horblyuk R, Kaplan HS: Economic measurement of medical errors using a hospital claims database. Value Health 16:305-310, 2013. 4. De Vries EN, Prins HA, Crolla RM, den Outer AJ, van Andel G, van Helden SH, Schlack WS, van Putten MA, Gouma DJ, Dijkgraaf MG, Smorenburg SM, Boermeester MA: Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med 363:1928-1937, 2010.
2
www.SCIENCEDIRECT.com
climate in neurosurgical ORs. McLaughlin et al. appropriately note that one limitation of this study is that the modified survey used has not been validated. Some variability in the “strength” of agreement was observed between the departments and within the same department depending on the level of training, but overall, the answers and degree of agreement were quite similar between groups. The study simply samples opinions and attitudes and does not compare these with and without an intervention, such as adoption of checklists. In addition, it does not attempt to establish a correlation between the safety attitudes and practices, including use of time-out, and a decrease in postoperative complications and mortality. This correlation has proven difficult to establish because of the low numbers of reported major preventable events from a single institution and the difficulty of aggregating results from multiple institutions using different safety protocols and reporting systems (9). Traditionally, knowledge and surgical skills have been considered to be the major elements of surgical training. More recently, the importance of nonsurgical skills, such as teamwork, interpersonal communication, leadership, and decision making, to patient safety outside and inside the ORs is being recognized (18). Globally, training programs are increasingly including some of these elements in their curriculum and its objectives. An excellent example is the CanMEDS Physician Competency Framework developed by the Royal College of Physicians and Surgeons of Canada. The seven roles of heath care providers identified by the CanMEDS educational framework are medical expert, communicator, collaborator, manager, health advocate, scholar, and professional. This model has been applied in many countries to health care and other professionals (6, 11). Adverse events have been estimated to affect 3%e16% of all hospitalized patients, and more than half of such events are thought to be preventable (17). An important initial step in prevention is to increase awareness among the health care providers of the impact of preventable errors on patients care. Faithful adherence to checklist and time-out protocols will enhance the safety attitudes in neurosurgical ORs and reduce the harm caused by adverse events.
5. Etchegaray JM, Thomas EJ: Comparing two safety culture surveys: safety attitudes questionnaire and hospital survey on patient safety. BMJ Qual Saf 21: 490-498, 2012. 6. Frank JR, Danoff D: The CanMEDS initiative: implementing an outcomes-based framework of physician competencies. Med Teach 29:642-647, 2007. 7. Fuller RL, McCullough EC, Bao MZ, Averill RF: Estimating the costs of potentially preventable hospital acquired complications. Health Care Financ Rev 30:17-32, 2009. 8. Gawande A: The checklist manifesto: how to get things right. New York, NY: Metropolitan Books; 2009. 9. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA: A surgical safety checklist to reduce morbidity and mortality
in a global population. N Engl J Med 360:491-499, 2009. 10. Kohn LT, Corrigan J, Donaldson MS: To err is human: building a safer health system. Washington, DC: National Academy Press; 2000. 11. Koo J, Bains J, Collins MB, Dharamsi S: Residency research requirements and the CanMEDS-FM scholar role: perspectives of residents and recent graduates. Can Fam Physician 58:e330-e336, 2012. 12. Lyons MK: Eight-year experience with a neurosurgical checklist. Am J Med Qual 25:285-288, 2010. 13. Mahajan RP: The WHO surgical checklist. Best Pract Res Clin Anaesthesiol 25:161-168, 2011. 14. McConnell DJ, Fargen KM, Mocco J: Surgical checklists: a detailed review of their emergence, development, and relevance to neurosurgical practice. Surg Neurol Int 3:2, 2012.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2013.08.039
PERSPECTIVES
15. McLaughlin N, Winograd D, Chung HR, van de Wiele B, Martin NA: Impact of the time-out process in a tertiary neurosurgical department on safety attitude. World Neurosurg 2013 Jul 25 [Epub ahead of print].
17. WHO: Guidelines for safe surgery, safe surgery saves lives, 2009. Available at: http://whqlibdoc. who.int/publications/2009/9789241598552_eng.pdf. Accessed November 20, 2013.
16. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA: An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 372:139-144, 2008.
18. Yule S, Flin R, Paterson-Brown S, Maran N: Nontechnical skills for surgeons in the operating room: a review of the literature. Surgery 139:140-149, 2006.
Citation: World Neurosurg. (2013). http://dx.doi.org/10.1016/j.wneu.2013.08.039 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com
WORLD NEUROSURGERY - [-]: ---, MONTH 2013
1878-8750/$ - see front matter ª 2013 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org
3