A new study (Bandari 2012) demonstrates how structured tools for OR briefings and debriefings can identify a whole host of patient safety issues. They used simple checklist-style tools for briefing before and debriefing after cases in their OR and found 141 “defects” per month, the detection rates about equally divided between the briefings and debriefings. They used standard categories to group defects identified. Equipment issues were the most commonly identified defects but communication issues were also common. Equipment issues ranged from identifying equipment that needed repair or replacement, issues on cleaning and sterility, setting up for cases, to training staff on use of certain equipment. They also noted how often staff were pulled away from or interrupted in their tasks to deal with such issues. The online version of the article provides copies of the tools used.
Other examples of such checklists for the preoperative briefings may be found on either the NHS Patient Safety First website or the VA website. Video examples of preoperative briefings may also be found at the NHS website or the VA website.
Preoperative briefings (sometimes called “huddles”) and postoperative debriefings are tools we have strongly recommended since we first began talking about the TeamSTEPPS™ training program back in 2007 (see our our May 22, 2007 Patient Safety Tip of the Week “More on TeamSTEPPS™” and our March 2009 What’s New in the Patient Safety World column “Surgical Team Training”). Briefings and debriefings are also core components of many of the crew resource management programs such as the VA’s Medical Team Training Program (see our January 11, 2011 Patient Safety Tip of the Week “NPSA (UK) ‘How to Guide’: Five Steps to Safer Surgery”).
Basically, in the debriefings you are asking “What went well?”, “What didn’t go well?” and “What could we do better next time?”. As above, you’ll often identify the need to fix broken equipment or ensure the availability of appropriate backup instruments. Sometimes it’s something simple like tray set-ups or equipment set-ups that interfered with the surgeon’s movements during the procedure.
Checklists have been utilized more often for the preoperative briefings or huddles. We previously noted a study by Lingard et al (Lingard 2008) that used a checklist to structure short team briefings and documented reduction in the number of communication failures. Another group (Paull 2010) demonstrated that implementation of preoperative checklist-driven briefings was associated with increased compliance with antibiotic prophylaxis and DVT prophylaxis.
Checklists that are too complicated are not good. We do have a tendency to add too many things to the checklists. Generally you should keep checklists to fewer than 10 items. Checklists should also be reviewed and revised as needed. Items that are not providing useful information can be deleted. Our December 9, 2008 Patient Safety Tip of the Week “Huddles in Healthcare” discussed an article by Nundy and colleagues at Johns Hopkins (Nundy 2008). They used a very simple format for pre-operative briefings that led to a 31% reduction in unexpected delays in the OR and a 19% reduction in communication breakdowns that lead to delays. The tool they used was simple and consisted of 5 key items:
But one of the unsaid messages in the Nundy paper is the KISS (“Keep It Simple, Stupid”) principle. Anticipate things and try to discuss the most serious things that might happen, but don’t make the process so complex and long that team members lose their attention. A typical pre-op huddle or briefing ordinarily takes no more than 3-4 minutes.
Some of the issues that might be discussed in a pre-op briefing/huddle are:
While each checklist should be kept short and simple, you can use “cascading” checklists (akin to the examples used in industry provided by Atul Gawande in his book “The Checklist Manifesto”). The best medical example of the cascading checklist is that for surgical fires. Our January 2011 What’s New in the Patient Safety World column “Surgical Fires Not Just in High-Risk Cases” noted an effort to promote fire safety in the OR (Murphy 2010) in which the San Francisco VA developed a checklist “The Surgical Fire Assessment Protocol”. This checklist/protocol is actually printed on the reverse side of their larger preoperative briefing checklist. It’s a good example of how you can use “cascading” checklists to avoid putting too many items on a single checklist.
Importantly, the mere performance of the briefings and debriefings fosters a sense of belonging to teams, empowerment for all members, and better communication. These lead not only to a culture of safety but they also significantly improve job satisfaction for all involved.
And don’t forget: huddles are not just for the OR! Our December 9, 2008 Patient Safety Tip of the Week “Huddles in Healthcare” also discussed how huddles and briefings can be useful in a variety of healthcare situations, not just the preoperative one.
Update: see our July 22, 2014 Patient Safety Tip of the Week “More on Operating Room Briefings and Debriefings”
Bandari J, Schumacher K, Simon M, et al. Surfacing Safety Hazards Using Standardized Operating Room Briefings and Debriefings at a Large Regional Medical Center. The Joint Commission Journal on Quality and Patient Safety 2012; 38(4): 154-160
NHS Patient Safety First. video demonstrating sample pre-op briefings
NHS Patient Safety First. Quick guide to briefing and debriefing.
Veterans Health Administration. Preoperative Briefing Guide for Use in the Operating Room.
Veterans Health Administration. Postoperative Briefing Guide for Use in the Operating Room.
Veterans Health Administration. Preoperative Briefing Video.
Lingard L, Regehr G, Orser B, et al. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication. Arch Surg, Jan 2008; 143: 12-17
Paull DE, Mazzia LM, Wood SD, et al. Briefing guide study: preoperative briefing and postoperative debriefing checklists in the Veterans Health Administration medical team training program. Am J Surg 2010; 200(5): 620-623
Nundy S, Mukherjee A, Sexton JB, et al. Impact of Preoperative Briefings on Operating Room Delays: A Preliminary Report. Arch Surg 2008; 143(11): 1068-1072
Murphy J. A New Effort to Promote Fire Safety in the OR. Topics In Patient Safety (TIPS) 2010; 10(6): 3
SF VAMC Surgical Fire Risk Assessment Protocol