Changing Operating Room Culture: Implementation of a Postoperative Debrief and Improved Safety Culture

Mapping Strategies for Strengthening Safety Culture: A Scoping Review

BACKGROUND

Twenty years after the "To Err Is Human" report, one in ten patients still suffer harm in hospitals in high-income countries, highlighting the need to strengthen the culture of safety in healthcare. This scoping review aims to map patient safety culture strengthening strategies described in the literature.

METHOD

This scoping review follows the JBI methodology. It adhered to all scoping review checklist items (PRISMA-ScR) with searches in the Lilacs, MedLine, IBECS, and PubMed databases and on the official websites of Brazilian and North American patient safety organizations. The research took place during the year 2023.

RESULTS

In total, 58 studies comprising 52 articles and 6 documents from health organizations were included. Various strategies were identified and grouped into seven categories based on similarity, highlighting the need for a comprehensive organizational approach to improve patient care. The most described strategies were communication (69%), followed by teamwork (58.6%) and active leadership (56.9%).

CONCLUSION

The identified strategies can promote the development of a culture in which an organization can achieve patient safety, involving practices and attitudes that reduce risks and errors in healthcare. However, the identification of strategies is limited because it is restricted to certain databases and websites of international organizations and does not cover a broader spectrum of sources. Furthermore, the effectiveness of these strategies in improving patient safety culture has not yet been evaluated.

Debriefing to improve interprofessional teamwork in the operating room: A systematic review

PURPOSE

Debriefing has been pivotal in medical simulation training, but its application to the real-world operating room environment has been challenging. We reviewed the literature on routine surgical debriefing with special reference to its implementation, barriers, and effectiveness.

DESIGN

Descriptive systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

METHODS

Inclusion criteria were papers pertaining to debriefing in routine surgical practice. Excluded were papers reporting simulation training. We searched Google Scholar, CINAHL, Web of Science Core Collection, PsychINFO, Medline, Embase, and ProQuest Theses & Dissertations Global. The last search was performed on March 14, 2022. Quality was assessed on a 21-point checklist adapted from a standard reporting guideline. Synthesis was descriptive.

FINDINGS

The search process resulted in 19 papers. Publication dates ranged from 2007-2022. Study methods included surveys, interviews, and analysis of administrative data. Five papers involved a specific intervention. Quality scores ranged from 12-19 out of 21. On synthesis, we identified five topics: explanations of how debriefing had been implemented; the value of coaching and audit; the learning dimensions of debriefing, both team learning and quality improvement at the organizational level; the effect of debriefing on patient safety or the organization's culture; and barriers to debriefing.

CONCLUSIONS

Successful implementation programs were characterized by strong commitment from management and support by frontline workers. Integration with administrative quality and safety processes, and information feedback to frontline workers are fundamental to successful debriefing programs.

CLINICAL RELEVANCE

Debriefing can improve teamwork, learning, and psychological safety but is difficult to practice in the operating room environment. It is relevant to review the benefits and barriers to debriefing, and to learn from the experience of others, in order to run better debriefing models in our own hospitals.

[Safety culture in the operating room-an overview]

Reduction and treatment of complications can be achieved through improvement of treatment options, complication management, and the abilities to remedy complications, and through the minimization of errors, respectively. Human-medical error represents an inappropriate treatment, for instance, not administered carefully, correctly or in a timely manner. It can cover all areas of physician-related and medical activities with regard to prophylaxis, diagnosis, selection of treatment modalities, and post-operative care. Different options to minimise errors are the improvement of organizational measures, technical skills and non-technical skills, like social competences. On the basis of a narrative literature research, systems and methods were gathered to describe the possibilities of error identification, research into the causes, and the avoidance of errors.

Analyzing and Discussing Human Factors Affecting Surgical Patient Safety Using Innovative Technology: Creating a Safer Operating Culture

INTRODUCTION

Surgical errors often occur because of human factor-related issues. A medical data recorder (MDR) may be used to analyze human factors in the operating room. The aims of this study were to assess intraoperative safety threats and resilience support events by using an MDR and to identify frequently discussed safety and quality improvement issues during structured postoperative multidisciplinary debriefings using the MDR outcome report.

METHODS

In a cross-sectional study, 35 standard laparoscopic procedures were performed and recorded using the MDR. Outcome data were analyzed using the automated Systems Engineering Initiative for Patient Safety model. The video-assisted MDR outcome report reflects on safety threat and resilience support events (categories: person, tasks, tools and technology, psychical and external environment, and organization). Surgeries were debriefed by the entire team using this report. Qualitative data analysis was used to evaluate the debriefings.

RESULTS

A mean (SD) of 52.5 (15.0) relevant events were identified per surgery. Both resilience support and safety threat events were most often related to the interaction between persons (272 of 360 versus 279 of 400). During the debriefings, communication failures (also category person) were the main topic of discussion.

CONCLUSIONS

Patient safety threats identified by the MDR and discussed by the operating room team were most frequently related to communication, teamwork, and situational awareness. To create an even safer operating culture, educational and quality improvement initiatives should aim at training the entire operating team, as it contributes to a shared mental model of relevant safety issues.

The surgical debrief: Just another checklist or an instrument to drive cultural change?

INTRODUCTION

Post-procedural debrief is recommended to improve patient safety. We examined operating room (OR) clinicians' perceptions of the impact of a multi-disciplinary debrief on OR culture.

METHODS

A survey was administered to 182 OR clinicians at a major academic medical center. Attitudes toward the surgical debrief and its effect on patient safety and OR culture were evaluated.

RESULTS

Majority of clinicians (58.2%) believed creating a culture of safety in the OR was a shared care team responsibility, however, surgical attendings and trainees were more likely to assign this responsibility to the surgical attending. Few circulating nurses and trainees felt comfortable initiating a surgical debrief. Overall clinicians agreed that a debrief would impact both patient safety outcomes and OR culture.

CONCLUSIONS

Clinicians felt implementation of a surgical debrief would positively affect the OR culture of safety by improving interdisciplinary communication and influencing the power hierarchy that exists in many ORs.

An Examination of Factors That Predict the Perioperative Culture of Safety

The perioperative setting is an intricate, complicated work environment in which patients are vulnerable to adverse events. Using a convenience sample, we examined relationships between the length of perioperative nurse experience, perioperative nurse engagement, and an OR culture of safety. We explored differences in safety culture scores based on CNOR certification status. There was no significant relationship between the length of perioperative nurse experience and the level of OR culture of safety. However, perioperative nurse engagement had a significant relationship with an OR culture of safety (P < .001), and this factor was a significant predictor of an OR culture of safety (P < .001). Perioperative nurses who held CNOR certification had significantly higher culture of safety scores compared with those who did not (P = .004). Additional research on perioperative nurse engagement and factors relating to patient safety may help perioperative leaders develop and implement engagement strategies.

The United States Army Medical Command, becoming a learning organization

Purpose

This study aims to describe how the Army and the Army Medical Department matured as a learning organization (LO) during the period after the 2014 Military Health System Review through the incorporation of changes aimed at improving patient safety, data transparency and becoming a high-reliability organization (HRO). This study explores the relationship between HRO and LO concepts by adding to the body of knowledge in both disciplines.

Design/methodology/approach

Four large-scale system changes are presented and evaluated against the principles of the LO. Metric data were collected longitudinally and presented as submitted to several nationally-recognized organizations in healthcare quality and safety. Post initiative observations are paired with a corresponding LO principle to assess US Army Medical Command’s (MEDCOM’s) maturation as a LO. System changes/improvements and the advancement of LO principles are discussed.

Findings

System improvements, analyzed critically alongside paired LO principles, show strong correlation between high-reliability and LO principles. Despite inherent institutional barriers, this study demonstrates that, when leveraged effectively, the leadership hierarchy and command culture can accelerate transformation into an LO.

Originality/value

This study explores changes implemented in MEDCOM, as it evolved as a stronger LO. It demonstrates how healthcare organizations and other high-risk industries that embrace high-reliability concepts will become better LOs and expands current knowledge on how LO concepts in healthcare can affect better system accountability and improved patient safety. Organizations can learn from MEDCOM’s journey changes that can hasten progress toward adoption of LO principles, especially in hierarchical organizations.

Impact of the Norwegian National Patient Safety Program on implementation of the WHO Surgical Safety Checklist and on perioperative safety culture

Objectives

Our primary objective was to study the impact of the Norwegian National Patient Safety Campaign and Program on Surgical Safety Checklist (SSC) implementation and on safety culture. Secondary objective was associations between SSC fidelity and safety culture. We hypothesised that the programme influenced on SSC use and operating theatre personnel’s safety culture perceptions.

Setting

A longitudinal cross-sectional study was conducted in a large Norwegian tertiary teaching hospital.

Participants

We invited 1754 operating theatre personnel to participate in the study, of which 920 responded to the surveys at three time points in 2009, 2010 and 2017.

Primary and secondary outcome measures

Primary outcome was the results of the patient safety culture measured by the culturally adapted Norwegian version of the Hospital Survey on Patient Safety Culture. Our previously published results from 2009/2010 were compared with new data collected in 2017. Secondary outcome was correlation between SSC fidelity and safety culture. Fidelity was electronically recorded.

Results

Survey response rates were 61% (349/575), 51% (292/569) and 46% (279/610) in 2009, 2010 and 2017, respectively. Eight of the 12 safety culture dimensions significantly improved over time with the largest increase being ‘Hospital managers’ support to patient safety’ from a mean score of 2.82 at baseline in 2009 to 3.15 in 2017 (mean change: 0.33, 95% CI 0.21 to 0.44). Fidelity in use of the SSC averaged 88% (26 741/30 426) in 2017. Perceptions of safety culture dimensions in 2009 and in 2017 correlated significantly though weakly with fidelity (r=0.07–0.21).

Conclusion

The National Patient Safety Program, fostering engagement from trust boards, hospital managers and frontline operating theatre personnel enabled effective implementation of the SSC. As part of a wider strategic safety initiative, implementation of SSC coincided with an improved safety culture.

[Safety-II in daily clinical practice]

BACKGROUND

Providing patient safety is a central matter in health care requiring complex treatment processes containing many risks. In hospital care, adverse events and patient harm occur frequently. In this context, the safety sciences investigate causes and contributing factors of such events as well as improvement measures. With Safety-I and Safety-II, two complementary approaches come into play. While Safety-I aims to minimize adverse events, the Safety-II approach focuses on understanding the system as a whole whose normal operations can result in both desired and adverse events. With the implementation of the Critical Incident Report System (CIRS), the Safety-I approach (with a focus on errors and correction of negative consequences for patient safety) has become an integral part of the university hospital chosen for this study. The subject matter of this study is to determine if and how the Safety-II approach (focussing on normal operation and the understanding of positive effects for patient safety) is already in use and what measurements can support its integration in daily clinical practice.

METHOD

Through observation, the structures of daily feedback meetings (huddles) from six different hospital departments have been gathered to determine if they can be considered as potential starting points for the implementation of the Safety-II approach. The following expert interviews (n=7) discussed four potentials of the Safety-II approach using the Resilient Assessment Grid (RAG). Finally, a focus group discussed which measurements are central for the integration of the Safety-II approach in daily clinical practice.

RESULTS

The study shows that department teams partially follow the Safety-II approach. During team huddles, positive experiences are already exchanged. The expert interviews revealed that the RAG potentials respond, learn and anticipate have already been realized satisfactorily while the potential monitor fell behind. The focus groups regard the Safety-II approach more as a matter of corporate culture and less as a paradigm shift which is needed to be integrated into day-to-day business.

DISCUSSION

Successfully establishing the Safety-II approach requires a focus not just on unwanted occurrences. It is also necessary to focus on the often not directly apparent desired occurrences, which ensure patient safety, and to systematically reflect on them in order to contribute to the development of the organizational culture. Having a better understanding of how the system of daily clinical practice with all its subsystems works will make it possible to proactively counteract unwanted occurrences, for example through regular feedback sessions and debriefings, and to increase patient safety.

Clinical debriefing: A concept analysis

AIMS AND OBJECTIVES

The purpose of this paper is to enhance nursing and collaborative practice by presenting a concept analysis of clinical debriefing and introducing an operational definition.

BACKGROUND

Debriefing has taken many forms, using a variety of approaches. Variations and inconsistencies in clinical debriefing, and its related terms, still exist in the clinical setting.

DESIGN

Concept analysis.

METHODS

Walker and Avant's eight-step approach to concept analysis.

RESULTS

The defining attributes of clinical debriefing identified in this analysis are described as the five E's: educated/experienced facilitator, environment, education, evaluation and emotions. Antecedents identified in this analysis include the critical event, the desire or need to review such an event and the organizational awareness to execute clinical debriefs. The consequences of clinical debriefings are primarily advantageous and positively impact involved nurses, healthcare teams, patients and organizations. Empirical referents of clinical debriefing are complex and multifactorial. The productivity of a clinical debrief can be enhanced through a series of proposed questions. Together, the defining attributes, antecedents and consequences shape a proposed operational definition of clinical debriefing.

CONCLUSION

Clinical debriefing is a valuable tool within healthcare organizations. Debriefing can be a holistic, interprofessional, collaborative experience when all five defining attributes are present. Further investigation is required to standardise debriefing practices in clinical settings.

RELEVANCE TO CLINICAL PRACTICE

A concept analysis on clinical debriefing promotes uniformity of debriefing practices, reflective practice among nurses and healthcare teams, and contributes to nursing science by creating a platform for the development of practice standards, research and theory development.

Structured Feedback Enhances Compliance with Operating Room Debriefs

BACKGROUND

Surgical debriefs help reduce preventable errors in the operating room (OR) leading to patient injury. However, compliance with debriefs remains poor. The objective of this study was to evaluate the role of structured feedback to surgeons in improving compliance with and quality of surgical debriefs.

MATERIALS AND METHODS

Surgical cases at an 875-bed urban teaching hospital from January-June 2019 were audited via audio/video recording to evaluate debrief performance. Debriefs were evaluated for clinical completeness and teamwork quality via two structured forms. Surgeons received an evaluation of their debrief performance at two time points during the study period (February and April). Univariate and mixed-effects regression analyses were used to assess changes in debrief compliance and quality over time.

RESULTS

A total of 878 surgical cases performed by 61 surgeons were reviewed: 198 (22.6%) cases during Period 1 (P1), 371 (42.3%) P2, and 309 (35.1%) P3. The rate at which a debrief occurred was 62.1% in P1, 73.0% in P2, and 82.2% in P3 (P < 0.001). Debriefs were 1.96 (95% CI 1.31-2.95, P = 0.001) times more likely to be completed during P2 and 3.21 (95% CI 2.07-5.04, P < 0.001) times more likely during P3 compared to P1. The percent of debriefs initiated by the lead surgeon increased from 59.8% in P1, to 80.0% in P2, to 81.5% in P3 (P < 0.001).

CONCLUSIONS

Providing structured feedback to surgeons on their debrief performance was associated with improvements in compliance and completeness with debriefing protocols, OR teamwork and communication, and leadership and accountability from the lead surgeons.

The Need for Surgical Safety Checklists in Neurosurgery Now and in the Future-A Systematic Review

Safety checklists have been studied among various surgical patient groups, but evidence of their benefits in neurosurgery remains sparse. Since the implementation of the World Health Organization's Surgical Safety Checklist, their use has become widespread. The aim of this review was to systematically review the state of the literature on surgical safety checklists in neurosurgery. Also, in the new era of robotics and artificial intelligence, there is a need to re-evaluate patient safety procedures in neurosurgery. A systematic review was conducted on PubMed, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials, Embase, and MEDLINE for articles published between 2008 and 2016 using MeSH (medical subject heading) terms and keywords describing postoperative complications and surgical adverse events, and some additional searches were carried out until January 2019. Twenty-six original studies or reviews were eligible for this review. They were categorized into studies with patient-related outcomes, personnel-related outcomes, or previous reviews. Checklist use in neurosurgery was found to reduce hospital-acquired infectious complications and to enhance operating room safety culture. Checklists seem to improve patient safety in neurosurgery, although the amount of evidence is still limited. Despite their shortcomings, checklists are here to stay, and new research is required to update checklists to meet the requirements of the transforming working environment of the neurosurgery operating room.

The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project

BACKGROUND

Conducting post-fall huddles is considered an integral component of a fall-risk-reduction program. However, there is no evidence linking post-fall huddles to patient outcomes or perceptions of teamwork and safety culture. The purpose of this study is to determine associations between conducting post-fall huddles and repeat fall rates and between post-fall huddle participation and perceptions of teamwork and safety culture.

METHODS

During a two-year demonstration project, we developed a system for 16 small rural hospitals to report, benchmark, and learn from fall events, and we trained them to conduct post-fall huddles. To calculate a hospital's repeat fall rate, we divided the total number of falls reported by the hospital by the number of unique medical record numbers associated with each fall. We used Spearman correlations with exact P values to determine the association between the proportion of falls followed by a huddle and the repeat fall rate. At study end, we used the TeamSTEPPS® Teamwork Perceptions Questionnaire (T-TPQ) to assess perceptions of teamwork support for fall-risk reduction and the Hospital Survey on Patient Safety Culture (HSOPS) to assess perceptions of safety culture. We added an item to the T-TPQ for respondents to indicate the number of post-fall huddles in which they had participated. We used a binary logistic regression with a logit link to examine the effect of participation in post-fall huddles on respondent-level percent positive T-TPQ and HSOPS scores. We accounted for clustering of respondents within hospitals with random effects using the GLIMMIX procedure in SAS/STAT.

RESULT

Repeat fall rates were negatively associated with the proportion of falls followed by a huddle. As compared to hospital staff who did not participate in huddles, those who participated in huddles had more positive perceptions of four domains of safety culture and how team structure, team leadership, and situation monitoring supported fall-risk reduction.

CONCLUSIONS

Post-fall huddles may reduce the risk of repeat falls. Staff who participate in post-fall huddles are likely to have positive perceptions of teamwork support for fall-risk reduction and safety culture because huddles are a team-based approach to reporting, adapting, and learning.

Evolution of Characteristics From Letters of Recommendation in General Surgery Residency Applications

OBJECTIVE

Letters of recommendation (LOR) describe applicants being considered for Surgery Residencies. Although objective measures have been studied, the descriptive language of LOR and changes over time has yet to be evaluated. The objective of this study was to evaluate the descriptions of autonomy, teamwork, and ACGME core competencies in the LOR of applicants over time.

DESIGN

After IRB approval, LOR of residents who matriculated into our Surgery Residency were evaluated. Residents were grouped into early (1973-1999) vs. late (2000-2016) applications, and generational groups (baby boomers: 1943-1960, generation X: 1961-1980, millennial: 1981-1999), to identify the following themes: autonomy, teamwork, ACGME core competencies, and technical skills. Content analysis was performed using Nvivo 11.

SETTING

Independent academic medical center.

PARTICIPANTS

LOR from 76 of 77 residents who matriculated into our Surgery Residency from 1973-2016.

RESULTS

255 LOR were available. Autonomy was described 175 times in 43 residents, and teamwork was described 263 times in 51 residents. Teamwork was more common in late vs. early applications (82% vs 53%; p = 0.007), and autonomy was present in 53% vs 61% of early vs late applications (p = 0.490). Teamwork was more commonly noted among millennial versus generation X and baby boomer applicants (92% vs 59% vs 47%; p = 0.006). Core competencies were detected 1445 times, with an increase in systems-based practice, and practice-based learning and improvement in early versus late applications (0 vs 16%, p = 0.001; 37% vs 74%, p = 0.025). Professionalism (68% vs 79%) and medical knowledge (74% vs 79%) were described consistently in early and late applications. Technical skills were described in 58% of early and 71% of late applications (p = 0.230).

CONCLUSIONS

LOR for surgery residency applicants has evolved over time with increased teamwork concepts. Descriptions of practice-based learning, system-based practice, research, and volunteerism have increased, while professionalism, medical knowledge, and technical skills were consistently described over time.