Patient safety in the operating room: an intervention study on latent risk factors

Three Years of Continuous Vital Signs Monitoring on the General Surgical Ward: Is It Sustainable? A Qualitative Study

Continuous monitoring of vital signs using a wireless wearable device was implemented in 2018 at a surgical care unit of an academic hospital. This study aimed at gaining insight into nurses' and patients' perspectives regarding the use and innovation of a continuous vital signs monitoring system, three years after its introduction. This qualitative study was performed in a surgical, non-intensive care unit of an academic hospital in 2021. Key-user nurses (nurses with additional training and expertise with the device) and patients were selected for semi-structured interviews, and nurses from the ward were selected for a focus group interview using a topic list. Transcripts of the audio tapes were deductively analysed using four dimensions for adoptions of information and communication technologies (ICT) devices in healthcare. The device provided feelings of safety for nurses and patients. Nurses and patients had a few issues with the device, including the size and the battery life. Nurses gained knowledge and skills in using the system for measurement and interpretations. They perceived the system as a tool to improve the recognition of clinical decline. The use of the system could be further developed regarding the technical device's characteristics, nurses' interpretation of the data and the of type of alarms, the information needs of patients, and clarification of the definition and standardization of continuous monitoring. Three years after the introduction, wireless continuous vital signs monitoring is the new standard of care according to the end-users at the general surgical ward.

Nurses' Perceptions of Patient Safety on Patient Safety Climate

PURPOSE

The purpose of this study was to determine the relationship between nurses' perception of patient safety and the safety climate.

DESIGN

Descriptive study.

METHODS

The sample consisted of 262 surgical nurses. Data were collected with an online questionnaire system using the Leiden Operating Theatre and Intensive Care Safety (LOTICS) Scale and Patient Safety Climate (PSC) Scale.

FINDINGS

Intensive care unit (ICU) nurses were found to have higher perceptions of patient safety (106.0 ± 15.2 vs 102.6 ± 17.0) and safety climate (59.2 ± 20.9 vs 50.9 ± 24.3) than Operating Room (OR) nurses. According to ICU nurses, OR nurses stated that teamwork was weak, they did not feel like a part of the team, and teamwork was incompatible. They stated that there was no preliminary information about the operation, that they could not get enough information during the operation, that sufficient materials were not available in the OR in case of need, and that the worn-out materials were not replaced and repaired in a timely manner.

CONCLUSION

As nurses' perception of patient safety increases; patient safety climate perceptions also increased. Providing both professional and in-service trainings to raise awareness of patient safety, developing strategies that prevent team conflicts, providing preliminary information about the surgery, and eliminating material deficiencies can increase nurses' perception of PSC.

Robotic Magnetic Surgery: Results From the First Prospective Clinical Trial

To evaluate a novel Magnetic Robotic Platform during reduced-port laparoscopic surgery in a prospective, multicenter clinical trial.

Background

Magnetic surgery has been developed to increase the benefits of minimally invasive surgery, with prior studies demonstrating its clinical benefits. Robotic-assisted surgery increases the surgeon's control over the instruments, offering less dependency on an assistant. The synergism of both techniques may escalate these individual benefits.

Methods

A prospective, multicenter, single-arm, open-label study was performed to assess the safety and performance of a robotic magnetic surgical system (Levita Robotic Platform). The investigational device was used during reduced-port laparoscopic cholecystectomy and laparoscopic bariatric surgery. The primary endpoints evaluated were safety and feasibility. Patients were followed for 30 days post-procedure.

Results

Between May 2021 and December 2021, 30 patients undergoing laparoscopic surgery were recruited. There were 22 females and 8 males with a mean age of 39 years (22-69 years) and median body mass index of 33 kg/m2 (21.6-50.4 kg/m2). Procedures included 15 gastric sleeves, 14 cholecystectomies, and 1 Roux en-Y gastric bypass. The procedures were successfully performed by utilizing the robotic magnetic surgical system and a reduced-port technique in all 30 patients. No device-related serious adverse events were reported. The device provided adequate visualization and retraction in all cases.

Conclusions

This clinical trial shows for the first time that this novel Magnetic Robotic Platform is safe and feasible in reduced-port laparoscopic cholecystectomy and laparoscopic bariatric surgery. This robotic platform brings the benefits of magnetic surgery in terms of reduction of incisions plus increasing the control for the surgeon.

Psychometric Properties of the Latin American Spanish Version of the Hospital Survey on Patient Safety Culture Questionnaire in the Surgical Setting

OBJECTIVE

The Hospital Survey on Patient Safety Culture (HSPSC) was designed to assess staff views on patient safety and has been translated and validated into several languages and settings. This study developed a Latin American Spanish version of the HSPSC for use in perioperative settings and examines its psychometric properties.

METHODS

After translation and adjustments, a web-based questionnaire was administered to all health care personnel at operating room in a public university-affiliated hospital in Popayán, Colombia. Descriptive statistics, internal reliability, confirmatory and exploratory factor analysis, and intercorrelations among survey composites were calculated.

RESULTS

Confirmatory factor analysis showed inadequate model fit for the original 12-factor structure of the HSPSC. Rather, a 9-factor, 36-item instrument showed acceptable factor loadings, internal consistency, and psychometric properties. Five factors were formed with minor changes. Adjusted factors emerged, like "staffing and work pressure" and "supervisor/manager expectations and actions promoting patient safety," "organizational learning-continuous improvement," and "hospital management support for safety," as well as "repeated errors and perception of safety." Internal consistency for each remaining composite met or exceeded a Cronbach α value of 0.60.

CONCLUSIONS

Psychometric analyses provided overall support for 9 of the 12 initial factors of patient safety culture. Our findings suggest that more validation studies need to be conducted before applying safety dimensions from the original HSPSC to perioperative settings only. By providing this initial tool, we hope to stimulate further studies and the patient safety research agenda in this part of the world.

Holistic nursing care among operating room nurses: Strengthening the standard of practice in Saudi Arabia

BACKGROUND

Holistic practices have been found beneficial for patients as well as nurses. They increase both the nurses and the patients' health-promoting behaviors, spirituality, and interpersonal relationships.

OBJECTIVE

This study aimed to determine holistic nursing care and compare its differences based on individual characteristics.

METHODS

This study employed a quantitative-cross sectional approach. It was conducted at the hospitals of Hail region, Kingdom of Saudi Arabia, from February 2020 to March 2020. Selected through convenience sampling, 154 operating room nurses participated in the study. Frequency and percentages were used to analyze the demographic information, and t-tests and analysis of variance were used to test for differences.

RESULTS

Holistic nursing dimensions such as physiological (4.72 ± 0.40), socio-cultural (4.53 ± 0.45), psychological (4.66 ± 0.32), and spiritual aspects (4.22 ± 0.73) were consistently carried out in the operating room. On the physiological dimension, no significant differences were found in years of experience [(t) -0.073; p > 0.942], gender [(t) -1.113; p > 0.27], or age [(F) 0.558; p > 0.57), but there was a significant difference with nationality [(t) -3.328; p < 0.001]. On the socio-cultural dimension, the length of experience [(t) 0.599; p > 0.550], gender, [(t) -1.420; p > 0.158], and age [(F) 0.148; p > 0.862] were not significant, but a significant difference was found with nationality [(t) -7.516; p < 0.001]. Regarding the psychological dimension, the length of experience [(t) -1.101; p > 0.276], gender [(t) -1.545; p > 0.129], and age [(F) 1.259; p > 0.287] were not significant, but there was a significant difference with nationality [(t) -5.492; p < 0.001]. Finally, with the spiritual dimension, no significant difference was found on length of experience [(t) -1.101; p > 0.276] or age [(F) 0.584; p > 0.559], but there were significant differences on gender [(t) -3.890; p < 0.001] and nationality [(t) -3.653; p < 0.001].

CONCLUSION

Nationality is a causal factor to physiological, socio-cultural, psychological, and spiritual dimensions, while gender is significant to spiritual aspect. Regardless of nationality or gender, nurses must be knowledgeable regarding the significance of adopting holistic care to improve the quality of their care to their patients.

Evaluation of the Impact of Intraoperative Distractions on Teamwork, Stress, and Workload

BACKGROUND

Within the operating rooms (ORs), distractions occur on a regular basis, which affect the surgical workflow and results in the interruption of urgent tasks. This study aimed to observe the occurrence of intraoperative distractions in Tunisian ORs and evaluate associations among distractions, teamwork, workload, and stress.

METHODS

This observational cross-sectional study was conducted in four different ORs (orthopedic, urology, emergency, and digestive surgery) of Sahloul University Hospital for a period of 3 mo in 2018. Distractions and teamwork were recorded and rated in real time during the intraoperative phase of each case using validated observation sheets. Besides, at the end of each operation, stress and workload of team members were measured.

RESULTS

Altogether, 50 cases were observed and 160 participants were included. Distractions happened in 100% of the included operations. Overall, we recorded 933 distractions that occurred once every 3 min, with a mean frequency of M = 18.66 (standard deviation [SD] = 8.24) per case. It is particularly noticeable that procedural distractions occurred significantly higher during teaching cases compared with nonteaching cases (M = 3.85, M = 0.60, respectively, P < 0.001). The mean global teamwork score was M = 3.85 (SD = 0.67), the mean workload score was M = 58.60 (SD = 24.27), and the mean stress score was M = 15.29 (SD = 4.00). Furthermore, a higher stress level among surgeons was associated with distractions related to equipment failures and people entering or exiting the OR (r = 0.206, P < 0.01 and r = 0.137, P < 0.01, respectively). Similarly, nurses reported a higher workload in the presence of distractions related to the work environment in the OR (r = 0.313, P < 0.05).

CONCLUSIONS

This study highlighted a serious problem, which often team members seem to ignore or underestimate. Taking our findings into consideration, we recommend the implementation of the Surgical Checklist and preoperative briefings to reduce the number of surgical distractions. Also, a continuous teamwork training should be adopted to ensure that OR staff can avoid or handle distractions when they happen.

Effect of an educational programme on the attitudes towards patient safety of operation room nurses

BACKGROUND

A culture of patient safety is one of the cornerstones of good-quality healthcare, and its provision is one of the significant challenges in healthcare environments.

AIM

The purpose of this study was to evaluate the effect of a surgical safety educational programme on the attitudes of nurses to patient safety in operating rooms (OR).

DESIGN

An interventional one-group pre-/post-test design, which sought to measure changes in OR nurses' attitudes toward patient safety culture.

METHODS

A simple random sampling technique was used to recruit 66 OR nurses working at six Royal Medical Service hospitals in Amman, Jordan. All participants took part in a 4-hour educational workshop. Pre-tests and post-tests were done.

RESULTS

The results of this study showed that OR nurses' attitudes towards a culture of patient safety was originally negative; significant improvement after attending the programme was found (3.3 ± 0.20 versus 3.8 ± 0.30). There was a negative correlation between years of experience and nurses' attitudes towards patient safety.

CONCLUSIONS

Incorporating courses about safety culture into continuing education programmes may improve nurses' attitudes towards patient safety. Nurses should be qualified to play an important role in creating a culture of patient safety.

Transmigration of a retained surgical sponge: a case report

Background

A retained surgical sponge remains a dreaded complication of modern surgery. Despite the increasing focus on patient safety instances of “a sponge being left in the abdomen”, are all too common in popular media. In this article we report the rare phenomenon of transmigration of a retained surgical sponge in a patient who underwent laparoscopic sterilization.

Case presentation

A 30-year-old female presented with progressive abdominal pain for about one month and vomiting with obstipation for 2 days. The patient had undergone laparoscopic sterilization 7 years back and then underwent re-canalization one year back. She underwent an exploratory laparotomy for suspected adhesive small bowel obstruction. During surgery, an intra-luminal surgical sponge was recovered from the distal small bowel. The patient recovered and was discharged in good health.

Conclusion

Despite numerous advances in terms of technology and the ever-growing emphasis on patient safety, the problem of a retained surgical sponge remains a dreaded potential complication. All clinicians and health care professionals should be aware of this entity and its various presentations.

Gating the holes in the Swiss cheese (part I): Expanding professor Reason's model for patient safety

INTRODUCTION

Although patient safety has improved steadily, harm remains a substantial global challenge. Additionally, safety needs to be ensured not only in hospitals but also across the continuum of care. Better understanding of the complex cognitive factors influencing health care-related decisions and organizational cultures could lead to more rational approaches, and thereby to further improvement.

HYPOTHESIS

A model integrating the concepts underlying Reason's Swiss cheese theory and the cognitive-affective biases plus cascade could advance the understanding of cognitive-affective processes that underlie decisions and organizational cultures across the continuum of care.

METHODS

Thematic analysis, qualitative information from several sources being used to support argumentation.

DISCUSSION

Complex covert cognitive phenomena underlie decisions influencing health care. In the integrated model, the Swiss cheese slices represent dynamic cognitive-affective (mental) gates: Reason's successive layers of defence. Like firewalls and antivirus programs, cognitive-affective gates normally allow the passage of rational decisions but block or counter unsounds ones. Gates can be breached (ie, holes created) at one or more levels of organizations, teams, and individuals, by (1) any element of cognitive-affective biases plus (conflicts of interest and cognitive biases being the best studied) and (2) other potential error-provoking factors. Conversely, flawed decisions can be blocked and consequences minimized; for example, by addressing cognitive biases plus and error-provoking factors, and being constantly mindful. Informed shared decision making is a neglected but critical layer of defence (cognitive-affective gate). The integrated model can be custom tailored to specific situations, and the underlying principles applied to all methods for improving safety. The model may also provide a framework for developing and evaluating strategies to optimize organizational cultures and decisions.

LIMITATIONS

The concept is abstract, the model is virtual, and the best supportive evidence is qualitative and indirect.

CONCLUSIONS

The proposed model may help enhance rational decision making across the continuum of care, thereby improving patient safety globally.

Aviation and healthcare: a comparative review with implications for patient safety

Safety in aviation has often been compared with safety in healthcare. Following a recent article in this journal, the UK government set up an Independent Patient Safety Investigation Service, to emulate a similar well-established body in aviation. On the basis of a detailed review of relevant publications that examine patient safety in the context of aviation practice, we have drawn up a table of comparative features and a conceptual framework for patient safety. Convergence and divergence of safety-related behaviours across aviation and healthcare were derived and documented. Key safety-related domains that emerged included Checklists, Training, Crew Resource Management, Sterile Cockpit, Investigation and Reporting of Incidents and Organisational Culture. We conclude that whilst healthcare has much to learn from aviation in certain key domains, the transfer of lessons from aviation to healthcare needs to be nuanced, with the specific characteristics and needs of healthcare borne in mind. On the basis of this review, it is recommended that healthcare should emulate aviation in its resourcing of staff who specialise in human factors and related psychological aspects of patient safety and staff wellbeing. Professional and post-qualification staff training could specifically include Cognitive Bias Avoidance Training, as this appears to play a key part in many errors relating to patient safety and staff wellbeing.

Vital signs monitoring and nurse-patient interaction: A qualitative observational study of hospital practice

BACKGROUND

High profile safety failures have demonstrated that recognising early warning signs of clinical and physiological deterioration can prevent or reduce harm resulting from serious adverse events. Early warning scoring systems are now routinely used in many places to detect and escalate deteriorating patients. Timely and accurate vital signs monitoring are critical for ensuring patient safety through providing data for early warning scoring systems, but little is known about current monitoring practices.

OBJECTIVE

To establish a profile of nurses' vital signs monitoring practices, related dialogue, and adherence to health service protocol in New South Wales, Australia.

METHODS

Direct observations of nurses' working practices were conducted in two wards. The observations focused on times of the day when vital signs were generally measured. Patient interactions were recorded if occurring any time during the observation periods. Participants (n=42) included nursing staff on one chronic disease medical and one acute surgical ward in a large urban teaching hospital in New South Wales.

RESULTS

We observed 441 patient interactions. Measurement of vital signs occurred in 52% of interactions. The minimum five vital signs measures required by New South Wales Health policy were taken in only 6-21% of instances of vital signs monitoring. Vital signs were documented immediately on 93% of vitals-taking occasions and documented according to the policy in the patient's chart on 89% of these occasions. Nurse-patient interactions were initiated for the purpose of taking vital signs in 49% of interactions, with nurse-patient discourse observed during 88% of all interactions. Nurse-patient dialogue led to additional care being provided to patients in 12% of interactions.

CONCLUSION

The selection of appropriate vital signs measured and responses to these appears to rely on nurses' clinical judgement or time availability rather than on policy-mandated frequency. The prevalence of incomplete sets of vital signs may limit identification of deteriorating patients. The findings from this study present an important baseline profile against which to evaluate the impact of introducing continuous monitoring approaches on current hospital practice.

Checklist usage decreases critical task omissions when training residents to separate from simulated cardiopulmonary bypass

OBJECTIVE

Separation from cardiopulmonary bypass (CPB) requires multiple preparatory steps, during which mistakes, omissions, and human errors may occur. Checklists have been used extensively in aviation to improve performance of complex, multistep tasks. The aim of this study was to (1) develop a checklist using a modified Delphi process to identify essential steps necessary to prepare for separation from CPB, and (2) compare the frequency of completed items with and without the use of a checklist in simulation. It was hypothesized that the use of a checklist would reduce the number of omissions.

DESIGN

High-fidelity simulation study.

SETTING

University-affiliated tertiary care facility.

PARTICIPANTS

Seven cardiac anesthesiologists created a checklist using a modified Delphi process. Ten residents participated in 4 scenarios separating from CPB in simulation.

INTERVENTIONS

Each scenario was performed first without a checklist and then again with a checklist. An observer graded participants' performance.

MEASUREMENTS AND MAIN RESULTS

A pre-separation checklist containing 9 tasks was created using the Delphi process. Without using this checklist, 4 tasks were completed in at least 75% of scenarios, and 8 tasks were completed at least 75% of the time when using the checklist. There was a significant improvement in completion of 5 of the 9 items (p< 0.01).

CONCLUSIONS

A modified Delphi process can be used to create a checklist of steps in preparing to separate from CPB. Using this checklist during simulation resulted in increased frequency of completing designated tasks in comparison to relying on memory alone. Checklists may reduce omission errors during complex periods of anesthesiologists' perioperative workflow.

Rescue bedside laparotomy in the intensive care unit in patients too unstable for transport to the operating room

INTRODUCTION

The prognoses of critically ill patients with a requirement for emergency laparotomy and severe respiratory and/or hemodynamic instability precluding transport to the operating room (OR) are often fatal without surgery. Attempting emergency surgery at the bedside might equally result in an adverse outcome. However, risk factors and predictors that could support clinical decision making have not been identified so far. This study describes the clinical characteristics, indicative pathophysiology and outcomes in patients undergoing resuscitative laparotomy in the intensive care unit (ICU).

METHODS

This was a retrospective observational study of all critically ill adult patients undergoing resuscitative laparotomy in the ICUs of a German university hospital from January 2005 to July 2013. Clinical characteristics, risk factors, and treatments were compared between survivors and non-survivors. The primary endpoint was 28-day survival.

RESULTS

A total of 41 patients with a median age of 64 (21 to 83) were included. The most frequent reasons for ICU admission were sepsis, pneumonia, and pancreatic surgery. All patients were mechanically ventilated, receiving vasopressors, and were in multiple organ failure. Twenty-nine patients (70.7%) were on renal replacement therapy and two patients (4.9%) on extracorporeal membrane oxygenation. The main reasons for surgery were suspected intra-abdominal bleeding (39.0%), suspected intestinal ischemia (24.4%) or abdominal compartment syndrome (24.4%). Twenty-eight-day, ICU and hospital mortalities were 75.6%, 80.5%, and 82.9%, respectively. In six out of ten patients (60%) who survived surgery for more than 28 days, bedside laparotomy was rated as a life-saving procedure by an interdisciplinary group of the investigators.

CONCLUSIONS

These findings suggest that in selected critically ill patients with a vital indication for emergency laparotomy and severe cardiopulmonary instability precluding transport to the OR, a bedside resuscitative laparotomy in the ICU can be considered as a rescue procedure, even though very high mortality is to be expected.

A survey of surgical team members' perceptions of near misses and attitudes towards Time Out protocols

BACKGROUND

Medical errors are inherently of concern in modern health care. Although surgical errors as incorrect surgery (e.g., wrong patient, wrong site, or wrong procedure) are infrequent, they are devastating events to experience. To gain insight about incidents that could lead to incorrect surgery, we surveyed how surgical team members perceive near misses and their attitudes towards the use of Time Out protocols in the operating room. We hypothesised that perceptions of near-miss experiences and attitudes towards Time Out protocols vary widely among surgical team members.

METHODS

This cross-sectional study (N = 427) included surgeons, anaesthetists, nurse anaesthetists, and operating room nurses. The questionnaire consisted of 14 items, 11 of which had dichotomous responses (0 = no; 1 = yes) and 3 of which had responses on an ordinal scale (never = 0; sometimes = 1; often = 2; always = 3). Items reflected team members' experience of near misses or mistakes; their strategies for verifying the correct patient, site, and procedure; questions about whether they believed that these mistakes could be avoided using the Time Out protocol; and how they would accept the implementation of the protocol in the operating room.

RESULTS

In the operating room, 38% of respondents had experienced uncertainty of patient identity, 81% had experienced uncertainty of the surgical site or side, and 60% had prepared for the wrong procedure. Sixty-three per cent agreed that verifying the correct patient, site, and procedure should be a team responsibility. Thus, only nurse anaesthetists routinely performed identity checks prior to surgery (P ≤ 0.001). Of the surgical team members, 91% supported implementation of a Time Out protocol in their operating rooms.

CONCLUSION

The majority of our surgical personnel experienced near misses with regard to correct patient identity, surgical site, or procedure. Routines for ensuring the correct patient, site, and surgical procedure must involve all surgical team members. We find that the near-miss experiences are a wake-up call for systematic risk reducing efforts and the use of checklists in surgery.