Patients' questions about orthopedic surgery; surgical errors; thiazide diuretics; iodophor-impregnated drapes - Evidence For Practice

AORN Journal, Feb, 2004 by George Allen

Patients' questions about joint replacement surgery

BMC Health Services Research

June 2003

Furnishing information to patients is an important component in the quest for the best possible outcome of any surgical procedure. The goal of this study was to determine what information patients want when they consult an orthopedic surgeon about undergoing either a total hip arthroplasty (THA) or a total knee arthroplasty (TKA). (1) Forty-eight patients considering THA (ie, 29) or TKA (ie, 19) who were seen at a university-affiliated tertiary care center orthopedic clinic or by an orthopedic surgeon at a community practice clinic, both in southern California, were asked to complete a written questionnaire. The questionnaire asked them to rate 30 questions on a five-point Likert scale in which one was the least important and five the most important. Common statistical methods, including percentages and medians, were used to analyze the results.

Findings. Overall, there was disagreement on question importance and variability in patients' preferences. The mean percentage of disagreement was 42% for questions answered by patients considering TKA and 47% for patients considering THA. There was enough agreement, however, to define a core set of four questions rated as most important (ie, with a score of five) that should be addressed.

* Am I going to need physical therapy?

* Will surgery affect my abilities to care for myself?

* How mobile will I be after surgery?

* When will I be able to walk normally again?

Clinical implications. This study showed that although there was enough agreement to define a core set of questions that should be addressed with the majority of patients considering THA or TKA, several of the remaining questions also were rated very important by some patients. The study authors suggest that the Internet may be one resource that is sufficiently flexible to accommodate the large variety of information needed. Perioperative nurses may find the 30 questions, especially the core questions identified by the study, useful as a framework for developing effective preoperative and postoperative educational tools for patients scheduled for these procedures.

Use of interviews to analyze surgical errors

Surgery

June 2003

Surgical errors occur frequently; however, not enough is known about the factors that cause them. Identifying and understanding the circumstances that cause these errors are key components in developing and implementing sustainable corrective actions. Root cause analysis as a method of identifying causative factors is labor intensive, time consuming, and consequently difficult to replicate on a large scale. This study was undertaken to test the feasibility and usefulness of conducting confidential interviews as a method of identifying patterns of surgical error causation. (2) A single surgeon interviewer conducted confidential interviews structured to gather detailed information about incident reports. Thirty-eight surgeons randomly selected from three teaching hospitals in Massachusetts agreed to participate and provided information about 146 incidents. The surgeons personally were aware of the circumstances that led to the errors about which they were interviewed. In each case, surgeons were asked to provide an open-ended description of an incident and recall factors that contributed to the error. They also were queried about the role of 15 possible contributing factors:

* administrative complexity/bureaucracy,

* communication breakdown among staff members,

* emergent versus elective setting,

* ergonomic problems,

* errors in judgment,

* excessive workload/inadequate staffing,

* failure of memory,

* failure of vigilance,

* fatigue,

* inappropriate protocols,

* interruption/distraction,

* lack of experience/competence at a task,

* lack of trainee supervision,

* technology failure, and

* time of day.

Common statistical methods were used to analyze the data gathered from the interviews.

Findings. Sixty percent of the incidents occurred in the OR, and 77% involved non-emergency care. Fifty-four percent resulted in temporary disability, 33% in permanent disability, and 13% in death. The most common factors contributing to errors were inexperience/lack of competence (ie, 53%), communication breakdown among staff members (ie, 43%), and fatigue or excessive workload (ie, 33%). Failure of judgment was directly associated with inadequate supervision (odds ratio [OR] = 3.4; 95% confidence interval [CI] = 1.2-9.6) while failure of vigilance was found to be inversely associated with inexperience as a reported contributing factor (OR = 0.51; 95% CI = 0.3-1.0).

Clinical implications. This study showed that confidential interviews with surgeons can generate detailed reports on a large number of surgical adverse events resulting from errors, consequently allowing important underlying factors to be identified. Perioperative managers should consider adding confidential interviews to their armaments of quality improvement processes.

Confidential interviews could be a viable alternative to root cause analysis and six sigma techniques for determining the fundamental cause of errors occurring in the perioperative environment.