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Industry: Email Alert RSS FeedDisruption in surgical flow
AORN Journal, Feb, 2008 by George Allen
Surgery
November 2007
Minor problems can decrease the compensatory resources of the surgical team, resulting in disruptions of surgical flow that have the potential to increase the occurrence of surgical errors. Additionally, surgical adverse events often are associated with technique-related procedures that occur during surgery, and many of these events are considered preventable. Little is known, however, about the factors, frequency, and nature of surgical-flow disruptions and their effects on the etiology of errors. Consequently, development of evidence-based interventions is extremely difficult.
Research in other complex settings, such as aviation, suggest that human error often is caused by a combination of active and latent failures and rarely is solely caused by an unsafe act of an individual. Interventions that target underlying systemic factors, therefore, are generally more effective than approaches that focus on individual characteristics. According to this perspective (ie, a systems approach), errors are the natural consequences, not causes, of the systemic breakdown among these factors that affect performance. Consequently, patient safety programs will be more successful when the intervention is made at specific failure points within the system rather than when the intervention focuses solely on the individual who committed the error. The goal of this prospective study was to observe surgical-flow disruptions and to evaluate their relationship to surgical errors within the context of cardiovascular surgery. This study is part of a larger research program whose goal is to provide a foundation to develop strategies of evidence-based interventions as well as the necessary methodology and measurement tools to validate the future of safety programs.
During a three-week period at a hospital in Rochester, Minnesota, a trained observer recorded surgical errors and flow disruptions during 31 randomly selected nonemergency cardiac surgery procedures. Events recorded by the observer were defined as any occurrence that seemed to disrupt the natural progression of the surgical procedure. A method of team-based consensus used to classify errors and flow disruptions resulted in a list of 155 technical operative errors and 341 recorded events that were considered surgical-flow disruptions.
Surgical-flow disruptions were divided into five categories:
* teamwork (ie, issues revolving around communication, team coordination, team familiarity, and team monitoring);
* extraneous interruptions (ie, disruptions occurring during a procedure that did not directly pertain to the treatment of the patient and resulted in disruption of surgical flow);
* equipment and technology (ie, malfunction of technologic equipment or delays secondary to equipment design or performance resulting in surgical delays);
* resource-based issues (ie, failure to progress to the next stage of the surgery because of a lack of resources);
* supervisory/training-related issues (ie, failure to progress to the next stage of the surgery because of management of personnel, guidance, and training of members of the OR team).
Common statistical techniques including the chi-square test and descriptive statistics were used to analyze the data.
FINDINGS. Most errors observed during the study were minor. About 60% (n = 37) of the surgical errors were noticed and managed immediately by the surgical team; 32% (n = 28) were events during which the team experienced difficulty performing a specific technique or procedure. Approximately 40% of the surgical errors were not detected immediately but were recognized and compensated for at a later time during the surgery. Errors that were captured immediately were significantly more likely to be detected by the person who committed the error than were events captured after a delay (66% of 57 events versus 41% of 25 events, respectively; [X.sup.2] = 8.735; P = .003).
Disruptions in surgical flow associated with problems in teamwork/communications accounted for the greatest percentage of these events (n = 178; 52%). Seventeen percent were associated with external/extraneous disruptions, 12% were associated with supervisory/ training-related distractions, 11% were associated with equipment/technology problems, and 8% were associated with issues of resource accessibility. The rate of errors made by the surgical team increased linearly with increases in the rate of surgical-flow disruptions (r = 0.47, P < .05).
CLINICAL IMPLICATIONS. The results of this study revealed that the rate of surgical errors increased significantly with increases in flow disruption and that teamwork/communications failures were the strongest predictor of surgical errors. The authors concluded that these findings provide preliminary data to develop evidence-based error management and patient safety programs within cardiac surgery. Perioperative nurses should be prepared to assist in the development of such programs.
Wiegmann DA, ElBardissi AW, Dearani JA, Daly RC, Sundt TM III. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery. 2007;142(5):658-665.
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