Are operating room distractions, interruptions and disruptions associated with performance and patient safety? A systematic review and meta-analysis

Patient safety in surgical settings: A study on the challenges and improvement strategies in adverse event reporting from a nursing perspective

AIMS

To explore adverse event reporting in the surgical department through the nurses' experiences and perspectives.

DESIGN

An exploratory, descriptive qualitative study was conducted with a theoretical-methodological orientation of phenomenology.

METHODS

In-depth interviews were conducted with 15 nurses, followed by an inductive thematic analysis.

RESULTS

Themes include motives for reporting incidents, consequences, feelings and motivational factors. Key facilitators of adverse event reporting were effective communication, knowledge sharing, a non-punitive culture and superior feedback.

CONCLUSION

The study underscores the importance of supportive organisational culture for reporting, communication and feedback mechanisms, and highlights education and training in enhancing patient safety.

IMPLICATIONS

It suggests the need for strategies that foster incident reporting, enhance patient safety and cultivate a supportive organisational culture.

IMPACT

This study provides critical insights into adverse event reporting in surgical departments from nurses' lived experience, leading to two primary impacts: It offers specific solutions to improve adverse event reporting, which is crucial for surgical departments to develop more effective and tailored reporting strategies. The research underscores the importance of an open, supportive culture in healthcare, which is vital for transparent communication and effective reporting, ultimately advancing patient safety.

REPORTING METHOD

The study followed the Standards for Reporting Qualitative Research and the Consolidated Criteria for Reporting Qualitative Research guidelines.

PATIENTS OR PUBLIC CONTRIBUTION

No patients or public contribution.

A Quantitative Analysis of Intraoperative Distractions and When They Occur During General Surgical Operations

Introduction Distractions in operating theatres prevent team members from concentrating on the complex tasks required for a successful operation. This can be a potential hazard to care for, and previously, correlations have been made between increased theatre distractions and adverse events. However, it remains unclear how frequently such events occur during routine care in theatres. The present study aims to quantify distractions and analyse any differences between staff groups, operative stages, and modes of operation. Methods A single-centre prospective study was conducted to assess disruptions in general surgical theatres. Events were recorded using a previously described categorization system on a proforma by a single researcher. The source and severity of distraction were recorded, as well as the mode of operation (elective/emergency), stage of operation, and staff team (scrubbed/floor). Results A total of 4,219 minutes of surgery were observed over four weeks, and 1,095 distraction events were recorded. Of the 14 elective and nine emergency procedures recorded, there was a mean of 54.8 distractions per procedure and a frequency of one distraction every three minutes and 51 seconds (15.6 hr-1). Irrelevant communication relating to the patient's case was the most common source, accounting for 24.7% of all distractions. The most frequently disrupted stage of the procedure for scrubbed staff was during anastomosis/resection for both elective and emergency procedures, with 16.9 and 32.6 distractions occurring per hour, respectively. Scrubbed staff were significantly more susceptible to distraction in emergency procedures than the floor staff. Discussion Our study reflects previous assessments with irrelevant communications and emergency procedures yielding the highest prevalence of distraction. This investigation provides novel information about the different stages of general surgery and the frequency of distractions that occur.

Nursing Students' Operating Room Experiences: A Qualitative Meta-Synthesis

PURPOSE

Missed nursing care is a condition that is likely to be encountered frequently in the surgical care process and is generally related to the educational and emotional needs of the patients. Perception of and witnessing missed care can affect nursing images, expectations, and experiences by causing nursing students to experience professional disappointment. The purpose of the study was to explore nursing students' perception of missed perioperative nursing care according to "role theory" and Benner's "novice to expert" theories.

METHODS

The study used a qualitative design based on Heidegger's hermeneutical phenomenological approach. Study data were collected using a semistructured interview form prepared by the researchers through face-to-face interviews lasting approximately 50 minutes. The analysis of the data was conducted using van Manen's thematic analysis. The Standards for Reporting Qualitative Research (SRQR) checklist was used in reporting the study.

RESULTS

This study, which was conducted to explore awareness of perioperative missed nursing care (PMNC), consisted of 12 students, including five males and seven females. Nursing students who noticed PMNC in clinical practice experienced internal conflict about the issue, were concerned about the image of nursing, and experienced role and professional identity confusion. The themes of the study were formed in light of these experiences of nursing students. Three themes and 11 subthemes emerged in the study. The themes of the study were (1) perceived PMNC applications-behavior patterns (2) internal reflections of PMNC-its impact on professional identity development and (3) perceptions of professionalism in perioperative nursing CONCLUSIONS: This study provided important data about the awareness of PMNC in the surgical clinical practice of nursing students in Turkey and the effects of this awareness on the professional roles and professional identity process. Students were aware of the behavioral patterns of PMNC and experienced internal conflict, anxiety about the nursing image, role confusion, and professional identity confusion due to this awareness. Some students justified the PMNC behaviors of the nurses and others saw themselves as the power to change the PMNC behaviors.

Nursing Students' Perception of Missed Perioperative Nursing Care: Hermeneutic Phenomenology

PURPOSE

Missed nursing care is a condition that is likely to be encountered frequently in the surgical care process and is generally related to the educational and emotional needs of the patients. Perception of and witnessing missed care can affect nursing images, expectations, and experiences by causing nursing students to experience professional disappointment. The purpose of the study was to explore nursing students' perception of perioperative missed nursing care (PMNC) according to "role theory" and Benner's "novice to expert" theories.

DESIGN

The study used a qualitative design based on Heidegger's hermeneutical phenomenological approach.

METHODS

Study data were collected using a semistructured interview form prepared by the researchers through face-to-face interviews lasting approximately 50 minutes. The analysis of the data was conducted using van Manen's thematic analysis. The Standards for Reporting Qualitative Research checklist was used in reporting the study.

FINDINGS

This study, which was conducted to explore awareness of PMNC, consisted of 12 students, including five males and seven females. It was understood that nursing students noticed PMNC in clinical practice, experienced internal conflict about the issue, were concerned about the image of nursing, and experienced role and professional identity confusion. The themes of the study were formed in light of these experiences of nursing students. Three themes and 11 subthemes emerged in the study. The themes of the study were (1) perceived PMNC application-behavior patterns, (2) internal reflections of PMNC-its impact on professional identity development, and (3) perceptions of professionalism in perioperative nursing.

CONCLUSIONS

This study provided important data about the awareness of PMNC in the surgical clinical practice of nursing students in Turkey and the effects of this awareness on the professional roles and professional identity process. Students were aware of the behavioral patterns of PMNC and that they experienced internal conflict, anxiety about the nursing image, role confusion, and professional identity confusion due to this awareness. Some students justified the PMNC behaviors of the nurses and others saw themselves as the power to change the PMNC behaviors.

Surgical System Efficiency and Operative Productivity in Public and Private Health Facilities in Ethiopia: A Cross-Sectional Evaluation

BACKGROUND

Global and local health organizations track surgical system efficiency to improve surgical system performance using various efficiency metrics, such as operating room (OR) output, surgical incision start time (SIST), turnover time (TOT), cancellation rate among elective surgeries, and in-hospital surgery wait time. We evaluated the surgical system efficiency and factors affecting the efficiency in health facilities across Ethiopia.

METHODS

A cross-sectional study design with retrospective record review was used to evaluate the surgical system efficiency in 163 public and private health facilities in Ethiopia from December 2020 to June 2021. Experienced, trained surgical clinicians abstracted efficiency data from service registers and patient charts using a pretested tool. A bivariable and multivariable regression analysis was conducted.

RESULTS

In the study facilities, 84.11% of the operating tables were functional, and 68,596 major surgeries were performed. The aggregate OR output in both public and private health facilities was 2 surgeries per day per OR table. Operating productivity was shown to be affected by first-case SIST (P=.004). However, of the total 881 surgery incision times audited, 19.86% of the first-of-the-day elective surgeries started after 10:01 am. The SIST was strongly associated with an in-hospital wait time for surgery (P=.016). The elective surgery cancellation rate was 5.2%, and aggregate mean TOT was 50.25 minutes. The mean in-hospital surgery wait time was 45.40 hours, longer than the national cutoff for wait time. In a bivariable analysis, the independent variables that demonstrated association operating room productivity were then inputted into a multivariable regression analysis model. However, none of the predictor/independent variables showed significance in the multivariable regression analysis model.

CONCLUSION

The volume of surgery and overall OR productivity in Ethiopia is low. This calls for concerted action to optimize OR efficiency and improve access to timely and safe surgical care in Ethiopia and other LMICs.

A Review of Cognitive Support Systems in the Operating Room

BACKGROUND

In recent years, numerous innovative yet challenging surgeries, such as minimally invasive procedures, have introduced an overwhelming amount of new technologies, increasing the cognitive load for surgeons and potentially diluting their attention. Cognitive support technologies (CSTs) have been in development to reduce surgeons' cognitive load and minimize errors. Despite its huge demands, it still lacks a systematic review.

METHODS

Literature was searched up until May 21st, 2021. Pubmed, Web of Science, and IEEExplore. Studies that aimed at reducing the cognitive load of surgeons were included. Additionally, studies that contained an experimental trial with real patients and real surgeons were prioritized, although phantom and animal studies were also included. Major outcomes that were assessed included surgical error, anatomical localization accuracy, total procedural time, and patient outcome.

RESULTS

A total of 37 studies were included. Overall, the implementation of CSTs had better surgical performance than the traditional methods. Most studies reported decreased error rate and increased efficiency. In terms of accuracy, most CSTs had over 90% accuracy in identifying anatomical markers with an error margin below 5 mm. Most studies reported a decrease in surgical time, although some were statistically insignificant.

DISCUSSION

CSTs have been shown to reduce the mental workload of surgeons. However, the limited ergonomic design of current CSTs has hindered their widespread use in the clinical setting. Overall, more clinical data on actual patients is needed to provide concrete evidence before the ubiquitous implementation of CSTs.

Identifying Built Environment Risk Factors to Provider Workflow and Patient Safety Using Simulation-Based Evaluation of a Pediatric ICU Room

OBJECTIVE

This study aimed to identify latent conditions in a pediatric intensive care unit (PICU) by analyzing characteristics of flow disruptions (FD) during a simulation of a three-phased scenario.

BACKGROUND

The built environment of healthcare facilities contributes to FD that can lead to clinical errors and patient harm. In the facility design process, there is an opportunity to identify built environment features that cause FD and pose safety risks. Simulation-based evaluation of proposed designs may help in identifying and mitigating safety concerns before construction and occupancy.

METHODOLOGY

During design development for a new 400-bed children's hospital, a series of simulations were conducted using physical mock-ups in a large warehouse. A three-phased scenario, (1) admission and intubation, (2) cardiac arrest, and (3) bedside surgery involving a cannulation to extracorporeal membrane oxygenation, was conducted in a PICU room mock-up. Each scenario was video recorded from four angles. The videos were systematically coded to identify FD.

RESULTS

Analysis identified FDs in three ICU zones: respiratory therapists (RT) zone, nurse zone, and head of the patient. Challenges in these zones were related to spatial constraints in the RT zone and head of the bed, equipment positioning in the RT zone and nurse zone, and impeded visibility related to the location of the boom monitor in the nurse zone.

CONCLUSION

Simulation-based evaluation of prototypes of patient care spaces can help identify characteristics of minor and major FD related to the built environment and can provide valuable information to inform the iterative design process.

Factors influencing teamwork in healthcare applicable to interventional and diagnostic radiology

Teamwork in healthcare has been analysed extensively in the literature, mainly in acute healthcare settings such as the operating room, emergency room, and intensive care unit, with limited evidence related to diagnostic and interventional radiology. Multiple factors that affect teamwork in different domains have been described, such as communication, hierarchy, and distractions. Teamwork is an important patient safety, job satisfaction and patient outcome determinant, with interprofessional and interdisciplinary healthcare education playing a relevant role in the different domains affecting team performance. The aim of this article is to review the literature to describe domains and specific factors that influence teamwork in diagnostic and interventional radiology practice. This is of particular interest for radiologist involved in quality improvement and/or patient safety initiatives development and implementation. The review will conclude with a summary table highlighting the most important factors that, according to the authors, appear relevant to the radiology practice.

Investigating the influence of selected leadership styles on patient safety and quality of care: a systematic review and meta-analysis

BACKGROUND

There is a popular belief that transformational leadership (TL) and servant leadership (SL) styles are influential in establishing a patient safety (PS) culture and improving the quality of care (QC). However, there are very few review articles investigating this phenomenon.

PURPOSE

This study performs a systematic review and meta-analysis to ascertain the influences of TL and SL on PS and QC.

METHODS

Published research work indexed in the two popular databases, that is, Scopus and PubMed, was selected based on the inclusion criteria. The systematic review was performed as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data such as country of publication, year, data type, research design, target population, sample size and conclusion were selected from the studies.

RESULTS

There are pieces of evidence suggesting a medium to strong effect of TL on PS. At the same time, the effect of TL on QC is not direct but indirect and is mediated through variables such as fostering positive organisational culture and enhancing organisational outcomes such as job satisfaction, leader effectiveness and willingness of nurses to spend some extra effort. A total of 27 studies were selected for final evaluation and 11 reported a relationship between TL and PS. The 'Fisher r-to-z transformed correlation coefficients' ranged from 0.3769 to 0.8673. Similarly, a total of four studies reported the relationship between TL and QC, 'Fisher r-to-z transformed correlation coefficients' ranged from 0.0802 to 0.5101, with most estimates being positive (80%).

CONCLUSION

TL has a strong and positive effect on PS but a positive and weak effect on the QC. There is not much evidence to establish SL's influence on PS and QC.

Associations of flow disruptions with patient, staff, and process outcomes: a prospective observational study of robotic-assisted radical prostatectomies

BACKGROUND

Technological advancements in the operating room (OR) have sparked new challenges for surgical workflow, OR professionals, and patient safety. Disruptive events are frequent across all surgical specialties, but little is known about their effects on patient outcomes and the influence of systemic factors. The aim was to explore the associations of intraoperative flow disruptions (FDs) with patient outcomes, staff workload, and surgery duration.

METHODS

Prospective, single-center, and multi-source study comprising direct and standardized OR observations of urologic surgical procedures, clinical patient outcomes, and staff- and patient-reported outcome data (PROMs; 3-month follow-up). All data were recorded between 01/2020 and 10/2021. FDs were assessed using standardized procedure observations. Linear and logistic regression analyses including multiple system factors were used to explore the effects of FDs on surgical outcomes.

RESULTS

61 robotic-assisted radical prostatectomy procedures were captured (with 61 patients and 243 staff reports). High rates of FDs were observed; however, our analyses did not show significant relationships with patient complication rates. Equipment- and patient-related FDs were associated with increased staff workload. No association was found between higher rates of FDs and procedure duration.

CONCLUSIONS

FDs were not related to inferior patient outcomes. Our findings may inform future OR investigations that scrutinize the complex interplay of human, team, process, and technological components that mitigate the effects of FDs during surgery.

Design guidelines for limiting and eliminating virtual reality-induced symptoms and effects at work: a comprehensive, factor-oriented review

Virtual reality (VR) can induce side effects known as virtual reality-induced symptoms and effects (VRISE). To address this concern, we identify a literature-based listing of these factors thought to influence VRISE with a focus on office work use. Using those, we recommend guidelines for VRISE amelioration intended for virtual environment creators and users. We identify five VRISE risks, focusing on short-term symptoms with their short-term effects. Three overall factor categories are considered: individual, hardware, and software. Over 90 factors may influence VRISE frequency and severity. We identify guidelines for each factor to help reduce VR side effects. To better reflect our confidence in those guidelines, we graded each with a level of evidence rating. Common factors occasionally influence different forms of VRISE. This can lead to confusion in the literature. General guidelines for using VR at work involve worker adaptation, such as limiting immersion times to between 20 and 30 min. These regimens involve taking regular breaks. Extra care is required for workers with special needs, neurodiversity, and gerontechnological concerns. In addition to following our guidelines, stakeholders should be aware that current head-mounted displays and virtual environments can continue to induce VRISE. While no single existing method fully alleviates VRISE, workers' health and safety must be monitored and safeguarded when VR is used at work.

Operating room team strategies to reduce flow disruptions in high-risk task episodes: resilience in robot-assisted surgery

In healthcare work settings, flow disruptions (FDs) pose a potential threat to patient safety. Resilience research suggests that adaptive behavioural strategies contribute to preventing cognitive overload through FDs at crucial moments. We aimed to explore the nature and efficacy of operating room (OR) team strategies to prevent FDs in robot-assisted surgery. Within a mixed-methods design, we first asked surgical professionals, which strategies they apply, and secondly, identified behavioural strategies through direct observations. Findings were analysed using content analysis. Additionally, FDs were assessed through live observations in the OR. The sample included four interviewed experts and 15 observed surgical cases. Sixty originally received strategies were synthesised into 17 final OR team strategies. Overall, 658 FDs were observed with external FDs being the most frequent. During high-risk episodes, FDs were significantly reduced (p < 0.0001). The identified strategies reveal how OR teams deliberatively and dynamically manage and mitigate FDs during critical tasks. Our findings contribute to a nuanced understanding of adaptive strategies to safeguard performance in robot surgery services. Practitioner Summary: Flow disruptions (FDs) in surgical work may become a severe safety threat during high-risk situations. With interviews and observations, we explored team strategies applied to prevent FDs in critical moments. We obtained a comprehensive list of behavioural strategies and found that FDs were significantly reduced during a specific high-risk surgical task. Our findings emphasise the role of providers' and teams' adaptive capabilities to manage workflow in high-technology care environments.

Mapping registered nurse anaesthetists' intraoperative work: tasks, multitasking, interruptions and their causes, and interactions: a prospective observational study

INTRODUCTION

Safe anaesthesia care is a fundamental part of healthcare. In a previous study, registered nurse anaesthetists (RNAs) had the highest task frequency, with the largest amount of multitasking and interruptions among all professionals working in a surgical team. There is a lack of knowledge on how these factors are distributed during the intraoperative anaesthesia care process, and what implications they might have on safety and quality of care.

OBJECTIVE

To map the RNAs' work as done in practice, including tasks, multitasking, interruptions and their causes, and interactions, during all phases of the intraoperative anaesthesia work process.

METHODS

Structured observations of RNAs (n=8) conducted during 30 procedures lasting a total of 73 hours in an operating department at a county hospital in Sweden, using the Work Observation Method By Activity Timing tool.

RESULTS

High task intensity and multitasking were revealed during preparation for anaesthesia induction (79 tasks/hour, 61.9% of task time spent multitasking), anaesthesia induction (98 tasks/hour, 50.7%) and preparation for anaesthesia maintenance (86 tasks/hour, 80.2%). Frequent interruptions took place during preoperative preparation (4.7 /hour), anaesthesia induction (6.2 /hour) and preparation for anaesthesia maintenance (4.3 /hour). The interruptions were most often related to medication care (n=54, 19.8%), equipment issues (n=40, 14.7%) or the procedure itself (n=39, 14.3%). RNAs' work was conducted mostly independently (58.4%), but RNAs interacted with multiple professionals in and outside the operating room during anaesthesia.

CONCLUSION

The tasks, multitasking, interruptions and their causes, and interactions during different phases illustrated the RNAs' work as done, as part of a complex adaptive system. Management of safety in the most intense phases-preparing for anaesthesia induction, induction and preparing for anaesthesia maintenance-should be investigated further. The complexity and adaptivity of the nature of RNAs' work should be taken into consideration in future management, development, research and education.

Intraoperative dynamics of workflow disruptions and surgeons' technical performance failures: insights from a simulated operating room

INTRODUCTION

Flow disruptions (FD) in the operating room (OR) have been found to adversely affect the levels of stress and cognitive workload of the surgical team. It has been concluded that frequent disruptions also lead to impaired technical performance and subsequently pose a risk to patient safety. However, respective studies are scarce. We therefore aimed to determine if surgical performance failures increase after disruptive events during a complete surgical intervention.

METHODS

We set up a mixed-reality-based OR simulation study within a full-team scenario. Eleven orthopaedic surgeons performed a vertebroplasty procedure from incision to closure. Simulations were audio- and videotaped and key surgical instrument movements were automatically tracked to determine performance failures, i.e. injury of critical tissue. Flow disruptions were identified through retrospective video observation and evaluated according to duration, severity, source, and initiation. We applied a multilevel binary logistic regression model to determine the relationship between FDs and technical performance failures. For this purpose, we compared FDs in one-minute intervals before performance failures with intervals without subsequent performance failures.

RESULTS

Average simulation duration was 30:02 min (SD = 10:48 min). In 11 simulated cases, 114 flow disruption events were observed with a mean hourly rate of 20.4 (SD = 5.6) and substantial variation across FD sources. Overall, 53 performance failures were recorded. We observed no relationship between FDs and likelihood of immediate performance failures: Adjusted odds ratio = 1.03 (95% CI 0.46-2.30). Likewise, no evidence could be found for different source types of FDs.

CONCLUSION

Our study advances previous methodological approaches through the utilisation of a mixed-reality simulation environment, automated surgical performance assessments, and expert-rated observations of FD events. Our data do not support the common assumption that FDs adversely affect technical performance. Yet, future studies should focus on the determining factors, mechanisms, and dynamics underlying our findings.