Patient Safety Tip of the Week

January 11, 2011

NPSA (UK) ‘How to Guide’: Five Steps to Safer Surgery


The UK National Health Service’s NPSA (National Patient Safety Agency) recently released its “How to Guide” Five Steps to Safer Surgery. It draws heavily on work done in the US on team training and techniques for improving communication in the perioperative period.


The five steps are:

  • Step one: Briefing
  • Step two: Sign in
  • Step three: Time out
  • Step four: Sign out
  • Step five: Debriefing


While you will all recognize steps 2-4 as those involved in the WHO Surgical Safety Checklist (see our Patient Safety Tips of the Week for July 1, 2008 “WHO’s New Surgical Safety Checklist” and January 20, 2009 “The WHO Surgical Safety Checklist Delivers the Outcomes” and September 23, 2008 “Checklists and Wrong Site Surgery”), the real focus of the new NPSA guide is on the briefings and debriefings.


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”).


Many of our columns have discussed teamwork, crew/cockpit resource management (CRM), communication, and handoffs. One of the problems we encounter in planning and implementing such team training programs, however, is measuring success of such programs. Many of the benefits of such teamwork training help the team function much better in emergency circumstances or in preventing unwanted events that are very rare to start with (eg. wrong site surgeries). But such events are likely to be absent in both pre- and post-intervention studies. Metrics of operating room efficiency can be used. But most assessments need to rely on process measures that are fairly labor-intensive to collect. 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. A study by Havlerson et al. from Northwestern Memorial Hospital (Halverson et al 2009) attempts to demonstrate the benefits of an intensive crew resource management training for all surgeons, anesthesiologists, OR nursing and ancillary personnel. The curriculum included a 4-hour training class plus some in-OR coaching. The intervention resulted in performance of a preoperative briefing in 86% of cases 2 weeks after the intervention but this fell to 66% at 6 months post-intervention. There was a modest improvement in formal announcement of intraoperative changes in staffing. There was no significant difference in timing of prophylactic antibiotic administration or case turnover times. A modest improvement in on-time first case starts may have been influenced by a concomitant intervention. A survey showed that 75% of participants had the perception that the briefings provided a better sense of teamwork. However, they noted a marked disparity in those perceptions by discipline, with nurses and anesthesiologists perceiving more benefit from the briefings than surgeons did.


But most such studies were measuring impact on perceptions and some “soft” outcomes. We needed confirmation that such team training programs and exercises actually led to improved patient outcomes. That evidence came late in 2010 when results of a visionary program at the Veterans’ Administration system were published (Neily 2010). Based upon a pilot project experience, the VA in 2006 began implementation of a Medical Team Training (MTT) program at all its hospitals nationwide. Using crew resource management (CRM) principles, clinicians were trained to work together as teams, challenge each other, use checklist-guided preoperative briefings and postoperative debriefings, and use other communication strategies. (For a thorough description of the VA MTT program see Dunn 2007). After a 2-month period of planning and preparation, each team attended a full-day session that included lecture and group interactive sessions, and videos. Over the next year, 4 structured followup telephone interviews were conducted to support, coach and assess the MTT implementation. The investigators were able to compare improvement in surgical mortality between those centers that had implemented MTT and those that had not yet done so. Using techniques to risk adjust and minimize bias, they concluded that the reduction in surgical mortality rate was 50% greater in those centers that had implemented MTT. Moreover, the found a dose-response relationship in which for every quarter of the program a reduction of 0.5 deaths per 1000 procedures occurred. They also looked at the impact of briefings and debriefings and found that for every increase in the degree of compliance with briefings and debriefings there was a reduction in the surgical mortality rate of 0.6 per 1000 procedures. The authors attributed much of the success of the program to the preoperative briefings. In addition to the statistical improvement in mortality they note they shared many stories of successes related to information revealed during the preoperative briefings. They also found that information from the postoperative debriefings was very useful in resolving issues such as fixing broken equipment, having appropriate backup instruments available, improving communication with radiology, etc. The same group (Paull 2010) also demonstrated that implementation of preoperative checklist-driven briefings was associated with increased compliance with antibiotic prophylaxis and DVT prophylaxis.


Another study evaluating the impact of an MTT program for the OR (Wolf 2010) showed significant reduction of case delays and sustained improvement in frequency of preoperative delays, handoff issues, equipment issues/delays, and adherence to antibiotic prophylaxis protocols.


The NPSA “Five Steps to Safety Surgery” also recommends use of IHI’s Surgical Trigger Tool or modifications to identify perioperative adverse events that can be measured and incorporated into your overall perioperative quality program.


Also most studies looking at CRM training have looked only at short-term outcomes. But our January 2010 What’s New in the Patient Safety World column “Crew Resource Management Training Produces Sustained Results” highlighted a study (Sax et al 2009) that demonstrated improved outcomes that have been sustained over the long run. Outcomes included increased use of preoperative checklists, increased self reporting, more reporting of near misses and environmental conditions, and several measures indicative of a culture of safety.


There are some key points in implementing such team training programs. One study on the VA MTT implementation (Paull 2009) noted that involvement of facility leadership (Director, Chief of Staff, Nurse Executive, Chief of Surgery, Chief of Anesthesiology, and OR Nurse Manager) was the factor most predictive of successful implementation of briefings/debriefings. The Dunn paper (Dunn 2007) stresses the importance of a “clinical” connection between the faculty and the other participants. Also, though the principles of CRM are rooted in aviation the program emphasizes that examples should all come from healthcare, not aviation. That paper has useful recommendations about scheduling the educational sessions, particularly ensuring a sufficient number of attendees to ensure adequate interactive discussion.


In all of these implementations, the preoperative briefings and the postoperative debriefings have been the most important component. In most cases they have been checklist-guided. 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.


Examples of such checklists for the postoperative debriefings may be found on either the NHS Patient Safety First website or the VA website. 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.


There is a science to developing checklists. In our September 23, 2008 Patient Safety Tip of the Week “Checklists and Wrong Site Surgery” we referenced an excellent guidance from the UK Civil Aviation Authority on the proper design, presentation and use of checklists. And our July 6, 2010 Patient Safety Tip of the Week “Book Reviews: Pronovost and Gawande” provided tips on checklist design and use from some of the works of Peter Pronovost and Atul Gawande.


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:

  • Names and roles of team players
  • Correct patient/procedure/site (“timeout”)
  • Prophylactic antibiotics given?
  • What are the critical steps of the procedure?
  • What are the potential problems in the case?


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:

  • Do we have all the necessary equipment? Implants? X-rays? Records?
  • Consent complete and correct?
  • Is a conversion to open procedure likely?
  • What kind of complications might we anticipate?
  • Is this a high risk case for surgical fire?
  • Will it be a long surgery?
  • If so, will we need to reposition patient?
  • If so, will we need DVT prophylaxis?
  • If so, will additional antibiotics be needed?
  • If so, will breaks or change of team members occur?
  • If so, will we need to ease up on traction temporarily?
  • If so, how will we be reminded to do all these things?
  • Will there be a surgical specimen for pathology?
  • Is a second timeout going to be needed (eg. multiple procedures or multiple surgical teams)?


We have long advocated that the surgical fire risk be discussed as part of the pre-op huddle (or pre-op briefing) and, if the case is considered high-risk, respective roles of all OR participants are called out during the surgical timeout. Our January 2011 “What’s New in the Patient Safety World” column 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. This is really a very good tool! The fire risk is assessed by a simple numerical scale. If the score is 3 (high risk) the rest of the form is filled out, which basically delineates the respective roles of all those participants. That’s a really good way to remind all about their responsibilities if a fire occurred. It’s also an example of how you can use “cascading” checklists to avoid putting too many items on a single checklist.


Most 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.


It is very apparent now that MTT programs and use of preoperative briefings (huddles) and postoperative debriefings are extremely useful tools that improve not only teamwork and communication but also result in improved efficiencies and improved patient outcomes. Those of you that have not yet implemented such programs should be strongly considering these valuable additions to your patient safety programs.


By the way, these 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.






NPSA (UK). How to guide to the five steps to safer surgery. December 10, 2010



NHS Patient Safety First. video demonstrating sample pre-op briefings



NHS Patient Safety First. Quick guide to briefing and debriefing.



Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, Espin S, Bohnen J, Whyte S. 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



Halverson AL, Andersson JL, Anderson K, et al. Surgical Team Training. The Northwestern Memorial Hospital Experience. Arch Surg 2009; 144(2):107-112



Neily J, Mills PD, Young-Xu Y, et al. Association Between Implementation of a Medical Team Training Program and Surgical Mortality. JAMA. 2010; 304(15): 1693-1700



Dunn EJ, Mills PD, Neily J, et al. Medical Team Training: Applying Crew Resource Management in the Veterans Health Administration. Jt Comm J Qual Patient Saf 2007; 33: 317-325



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



Wolf FA, Way LW, Stewart L. The Efficacy of Medical Team Training: Improved Team Performance and Decreased Operating Room Delays: A Detailed Analysis of 4863 Cases. Annals of Surgery 2010. 252(3): 477-485



IHI. Surgical Trigger Tool for Measuring Peri-operative Adverse Events (IHI Tool)



IHI. Surgical Trigger Tool Kit. August 2006



Sax HC, Browne P, Mayewski RJ, et al. Can Aviation-Based Team Training Elicit Sustainable Behavioral Change? Arch Surg. 2009; 144(12):1133-1137



Paull DE, Mazzia LM, Izu BS, et al. Predictors of successful implementation of preoperative briefings and postoperative debriefings after medical team training. Am J Surg 2009; 198(5): 675-678



VETERANS HEALTH ADMINISTRATION Preoperative Briefing Guide for Use in the Operating Room



VETERANS HEALTH ADMINISTRATION Postoperative Briefing Guide for Use in the Operating Room






Civil Aviation Authority (UK). CAP 676: Guidance on the Design, Presentation and Use

of Emergency and Abnormal Checklists. January 2006.



Nundy S, Mukherjee A, Sexton JB, Pronovost PJ,  Andrew Knight A, Rowen LC, Duncan M, Syin D, Makary MA. 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
















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