Communication failure in the operating room

Transcription

1 Communication failure in the operating room Amy L. Halverson, MD, a Jessica T. Casey, MD, b Jennifer Andersson, RN, c Karen Anderson, RN, d Christine Park, MD, e Alfred W. Rademaker, PhD, f and Don Moorman, MD, g Chicago, IL, and Pittsburgh, PA Background. Communication errors contribute to the occurrence of adverse events in various domains of health care. Recent studies surveying perceptions of communication in the operating room have found disparities in the perceived quality of communication among members of the operating room team. Our aim was to characterize the nature of communication failures observed in the operating room and to assess whether a Team Training curriculum had any impact on observed communication errors. Methods. Intraoperative observation was performed and communication errors were identified according to predetermined criteria. Observed errors were classified according to the type of error, subject matter, and observed effect. Results. Seventy-six communication failures were observed over 150 hours of observation. Overall, communication errors relating to equipment and keeping team members informed of the progress of an operation comprised 36% and 24% of all observed communication errors, respectively. Prior to the introduction of a Team Training curriculum, 56 errors were observed over 76 hours (rate,737 errors per hour; standard error, 0.098). After Team Training, 20 errors over 74 hours were observed (rate.270 errors per hour; standard error, 0.060; P <.001). Conclusion. Communication failures related most frequently to equipment and keeping team members updated as to the progress of an operation. These failures can lead to procedural delay and inefficiencies. A program that teaches teamwork and communication skills is one strategy that may improve communication among members of the operating room team. (Surgery 2010;j:j-j.) From the Departments of Surgery, a Urology, b Quality, c Surgical Services, d Anesthesia, e and Preventive Medicine, f Feinberg School of Medicine and Northwestern Memorial Hospital, Northwestern University, Chicago, IL; and Department of Surgery, West Penn Allegheny Health System, g Pittsburgh, PA COMMUNICATION ERRORS contribute to the occurrence of adverse events in various domains of health care. In root-cause analysis of more than 4,000 adverse events, the Joint Commission identified communication breakdown as the most common factor implicated in adverse events and made improving the effectiveness of communication among caregivers a patient safety goal for Recent studies surveying perceptions of communication in the operating room have found disparities in the perceived quality of communication among members of the operating room team. 2,3 In a prospective observational study, Christian et al identified communication and Accepted for publication July 30, Reprint requests: Amy L. Halverson, MD, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL ahalverson@nmff.org /$ - see front matter Ó 2010 Mosby, Inc. All rights reserved. doi: /j.surg information flow to be a primary point of vulnerability for patient safety and efficiency in the operating room. 4 Lingard et al developed a classification scheme for communication failures in the operating room. 5 In their study, observed communication errors were classified as errors of occasion, content, audience, or purpose. Although their strategy was sound methodologically, we found that it did not provide enough practical information to guide further efforts to improve communication. Therefore, we sought to characterize further the communication failures in the operating room by identifying the topics about which communication errors relate most frequently. We also evaluated the effects that the communication errors had on the workflow in the operating room. A more thorough understanding of the nature of communication failure in the operating room will help us develop strategies to improve communication among members of the operating room team. The primary aim of this study was to better understand the vulnerabilities of intra-operative SURGERY 1

2 2 Halverson et al Surgery j 2010 communication. A second aim was to assess whether the communication skills taught as part of Team Training curriculum affected the frequency or type of observed communication errors. METHODS Northwestern Memorial Hospital introduced a Team Training curriculum for individuals working in the operating room. 6 The trainees included surgeons and surgery residents, anesthesia providers, nurses, and other operating room personnel. The curriculum was based in part on the principles developed for Crew Resource Management in the aviation industry This curriculum introduced the concept of a preoperative briefing as a means to improve the shared understanding of the team members. The briefing covers issues related to the patient, equipment needs, and information about the operative procedure. The curriculum included a module on communication skills in which information transfer techniques, such as calling out critical information and reading back verbal requests, were taught. The trainees were also taught a standardized approach to hand off communications between team members. The handoffs were to include verbally announcing all handoffs to the members of the surgery team and introducing the replacement individuals. Intra-operative observation of operative procedures was performed by personnel from the Northwestern Memorial Hospital Department of Quality before and after the Team Training curriculum was introduced. Cases were observed over two 8-week periods; about 2 cases per day were observed. Cases were distributed across all days of the week, times within the day, surgical specialty, and surgeon within each specialty. A similar sampling scheme was used for observation both pre and post Team Training period. This methodology allowed for a representative sample of cases to enhance the ability to generalize the results beyond this sample. The post Team Training observation period occurred between 6 and 9 months after the curriculum rollout. A combination of a checklist and ethnographic field notes were used to record and categorize communication events. A communication event was defined as a verbal or nonverbal exchange between 2 or more team members. Observers recorded the time of event, participants, content, contextual features, and any immediate observable effects. Additionally, minute-to-minute observations were recorded freehand into each individual observer s field notes. Recorded observations included occurrences, such as entrances and exits of individuals, operative and anesthesia events, additions of instruments to the operative field, and counts of instruments. Field notes were analyzed by observers to identify failures in communication events among team members. This approach included reading of field notes and comparing any event of interest with other observations in order to develop a sense of pattern as described by Lingard et al. 5 Each communication failure was analyzed to determine the type of error, subject of error, and effect of the error on the workflow in the operating room. For the type of error, we used the classification scheme of Lingard et al, and observed communication errors were classified as errors of occasion, content, audience, or purpose. 5 Errors of occasion refers to an inappropriate physical or temporal situation of the exchange; errors of content refers to communication events for which information was inaccurate or missing; errors of audience refers to events in which appropriate individuals were not participating; and errors of purpose refers to unresolved goals, implicit or explicit, of the communication event. 5 In addition to the error classifications described by Lingard et al, we added errors of omission when appropriate communication was absent and errors of inappropriate communication to include offensive remarks. An observed communication error could be categorized according to more than 1 error type (Table II). The topics of the communication events were classified into 8 categories: equipment, progress report, medications, procedure, policy, environmental, personnel, and other. Equipment refers to operating room equipment or instruments. Progress report refers to updating the other team members as to the progress of the operation or any changes in the patient s status. Medications refers to administration of patient medications. Procedure relates to details about the operation such as patient positioning. Communication errors were classified in the policy category when an exchange of information as required by hospital policy did not happen. Environmental subject includes room temperature and extraneous noise. The personnel category included communication about status of individuals involved in the case (Table I). The effects of the error on the workflow of the operative room were classified into 8 categories, including: delay, inefficiency, tension, workaround, patient inconvenience, resource waste, procedural error, and none.

3 Surgery Volume j, Number j Halverson et al 3 Table I. Examples of communication failures Failure Type Subject Effect The resident requested that the circulator page the attending. The circulator did not hear the resident s request due to loud music. Several minutes elapsed before the resident realized the circulator did not hear his request. Surgeon asked for arch bars mentioned during discussion with nurse. The scrub nurse did not mention during the time out that the arch bars were not available. The circulator had to go out of the room to retrieve the instrumentation. Forty-five minutes after the first case was scheduled to start, the patient was not in the room. There was no communication between the preoperative area and the OR nurses regarding the reason for the delay. Surgeon said turn it down. The circulator turned down the volume of the music. The surgeon was referring to the room temperature. The circulating nurse called Time Out. No one stopped what they were doing. No one looked at her. Everyone kept talking. The circulator paused then continued the Time Out with no one paying attention to her. Occasion The music created an environmental barrier to effective communication Personnel Omission Equipment Delay Inefficiency Omission Progress report Tension Content Relevant information is missing Audience The communication did not reach the intended audience Environment Policy Time Outs are required by hospital policy None Procedural Error The observations were led by a team of 2 process improvement leaders, both of whom were registered nurses. One had 3 years experience in operational and quality improvement; the other had more than 9 years experience and doctoral-level training in qualitative research methodologies involving the structured observation of clinicians practicing in an acute care setting. Additional observers included 1 medical student with a background in communications and 3 operating room nurse managers. All observers were trained generally as observers and specifically with the instrument. Observers were given a series of scenarios to evaluate prior to actual observation in order to develop a common understanding of the various categories. After each of several observations, the field notes were reviewed with one of the Quality Leaders. The observers were not announced to the surgical team. All operating room team members, including all residents, nurses, staff surgeons, and scrub technicians were required to have undergone the team training curriculum before working in the operating room. In the rare instance that there was a newly hired person or an agency nurse who had not participated in the team training curriculum, the observers would not be aware. The Northwestern University Institutions Review Board approved the study and waived informed consent from the the persons observed. At the completion of observation, the field notes were reviewed individually and then discussed as a group for agreement of classification among one of the Quality Leaders and a team composed of a surgeon, nurse manager, and anesthesiologist who did not participate in the observations. None of the individuals were blinded as to whether the communication occurred pre or post Team Training. As individuals and collectively, limiting an observed event to a single type, category, or outcome was sometimes difficult. Differences of opinion were discussed until consensus was reached. Comparison of the observations from the pre and post Team Training periods was made using the normal approximation for comparing 2 Poisson rates.

4 4 Halverson et al Surgery j 2010 Table II. Type of communication errors Number of communication errors observed (%)* Type of error Pre team training Post team training Content 22 (25) 13 (39) Occasion 18 (20) 5 (15) Purpose 16 (18) 6 (18) Audience 13 (15) 8 (24) Omission 15 (17) 1 (3) Inappropriate 4 (5) 0 *Because a single communication event can be classified according to more than one type, numbers add up to more than 100%. Values are n (%). P =.14. RESULTS Seventy-six communication failures were observed over 150 hours of observation. Prior to the introduction of a Team Training curriculum, 56 errors were observed over 76 hours (rate, errors per hour, standard error, 0.098)). After the Team Training, 20 errors over 74 hours were observed (rate errors per hour, standard error 0.060, P <.001). There were no significant differences in the types of communication errors observed before and after Team Training (Table II). During the pre-team Training observation period, the observed communication errors related most commonly to equipment (23%) and progress report (32%). After Team Training, 70% of observed communication errors related to equipment (P <.001; Table III). The observed communication failures resulted in inefficiencies, delays, and increased tension among members of the operating room team (Figure). The observed effects were similar in the pre and post-team Training periods, P =.023. DISCUSSION The goals of this study were to analyze the nature and outcome of communication failures in the operating room and to assess whether a team training curriculum affected communication in the operating room. This study had methodologic limitations in that not all observations were performed by 2 observers; therefore we do not have data on interobserver reliability. An additional difficulty with this study is the problem of classifying and categorizing communication failures objectively. As discussed by Lingard et al, many observed failures could be categorized as more than one type of error. While our data collection was in part based on a validated instrument, we found that this instrument was not designed to Table III. Subject of communication errors Number of communication errors observed* Subject of error Pre team training Post team training Equipment 13 (23) 14 (70) Progress report 18 (32) 0 Policy 6 (11) 0 Medications 5 (9) 0 Procedure 7 (13) 1(5) Personnel 1 (2) 0 Environmental 2 (4) 3 (15) Other 4 (7) 2 (10) *Values are n (%). P < account for relevant communication that did not occur at all, which accounted for 21% of our observed errors overall. Due to the temporal nature of the observations, none of the observers were blinded to whether the operation was before or after the team training curriculum. We considered videotaping the operations to allow blinded observation, but decided that videotaping would be more disruptive to the procedures. Additionally, we thought that some communications or their effects might be missed by the relatively limited scope of a video camera. Despite the limitations outlined above, our observations added useful, actionable information about communication failure in the operating room. The 2 most common subjects leading to communication errors were equipment and progress reports. It was not surprising to us that the observed communication failures were related most commonly to equipment, because this is a very common subject of communication in general. In an observational study of communication in the operating room, Moss and Xiao found that coordinating the equipment was the most frequent subject of communication between charge nurses and other members of the operating room team, consisting of 39% of all observed communication events. 11 Further strategies to improve understanding of the equipment and the resources needed prior to an operation by the nurses and technicians may help to decrease the likelihood of miscommunication error related to equipment. The importance of communication among stakeholders has been addressed previously. Lee et al demonstrated recently that the implementation of an intraoperative pathway led to improvements in operative time, cost, quality measures, and staff satisfaction. This pathway incorporated

5 Surgery Volume j, Number j Halverson et al 5 Figure. (A) Observed consequences of communication failure in the operating room pre-team Training. (B) Observed consequences of communication failure in the operating room post-team Training. structured communication points including interphasic briefings in addition to the initial preoperative briefing. 12 Protocols whereby family members are notified at regular intervals regarding the progress of a procedure are helpful to decrease anxiety among family members. 13 Moss and Xiao observed patient preparedness as the second most common purpose of observed communication in the operating room. They suggest that automated tracking and status displays may be beneficial to streamline communication. 11 Preoperative briefings have been proposed as a method to improve the understanding of the procedure for members of the operating room team and potentially to decrease the risk of error We reported previously an observed decrease in compliance with preoperative briefing from 86% at 2 weeks after Team Training to 66% at 4 weeks after team training. 6 In this study, we did not count failure to perform a briefing as a communication failure. This degree of compliance is similar to that observed by France et al, who observed less than 60% compliance with safety practices after implementation of a program of surgery team training. 17 Based on the decreased compliance with the briefing over time, one may hypothesize that our observations reflected decay in communication skills over time as well. In a recent study, Lingard et al observed a significant decrease in communication errors after implementation of a briefing checklist. 18 The implementation of this checklist included a year-long process of stakeholder meetings and rapportbuilding prior to the implementation of the intervention as well as ongoing coaching after implementation. Through the administration of a survey, Nundy et al found that operating room team members perceived intraoperative delays less frequently after implementing a preoperative briefing. 19 It is unclear from this study the extent to which a preoperative briefing alone contributed to the observed decrease in communication failures. In conclusion, communication failures are often related to equipment and keeping team members informed about the progress of an operation. These failures can lead to procedure delays and inefficiencies. A program that teaches teamwork and communication skills is one strategy that may improve communication among members of the operating room team. REFERENCES 1. Disease-Specific Care Certification - National Patient Safety Goals. Oak Brook Terrace (IL): The Joint Commission; Available from: 2. Makary MA, Sexton JB, Freischlag JA, et al. Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder. J Am Coll Surg 2006;202: Mills P, Neily J, Dunn E. Teamwork and communication in surgical teams: implications for patient safety. J Am Coll Surg 2008;206: Christian CK, Gustafson ML, Roth EM, et al. A prospective study of patient safety in the operating room. Surgery 2006; 139: Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recurrent types and effects.[see comment]. Qual Saf Health Care 2004;13: Halverson AL, Andersson JL, Anderson K, et al. Surgical team training: the Northwestern Memorial Hospital experience. Arch Surg 2009;144: Helmreich RL, Musson DM. Surgery as team endeavour. Can J Anaesth 2000;47:391-2.

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