What’s New in the Patient Safety World

March 2012

Human Factors and Operating Room Safety



The February 2012 issue of Surgical Clinics of North America is dedicated to patient safety. It has multiple good articles on issues related to patient safety in the OR and other venues involved in surgical care.


The issue begins with an overview of high-reliability organizations (HRO’s) by Sanchez and Barach (Sanchez 2012). It describes the principles of high-reliability organizations that have managed to operate safely in other complex industries with capability of responding rapidly to changing conditions. In addition to the HRO literature, it also discusses James Reason’s Swiss cheese model of accident causation and Charles Perrow’s normal accident theory. It is particularly useful in its description of microsystems in an HRO and how clinical microsystems are of great importance in healthcare.


An article by ElBardissi and Sundt (ElBardissi 2012) on human factors and OR safety discusses both environmental and interpersonal aspects of OR design and function. They discuss factors in the OR layout that may impede good communication between all parties. These include positioning of equipment, the collection of wires/tubes/lines (the “spaghetti syndrome”), noise, and other factors that need to be considered in designing good surgical flow and information exchange. They have a very good discussion on the flexibility vs. standardization debate.


On reducing distractions related to noise, they discuss policies restricting the number of observers in the OR, radios, pagers, music, non-essential personnel movement, and non-case-related conversations. However, they note downsides to each of those recommendations as well and sometimes offer compromise positions. For example, noting that non-case-related conversations may have a role in promoting teamwork and job satisfaction, they suggest we adopt the sterile cockpit rule from aviation, in which such extraneous conversations are barred during critical phases of the case.


They also discuss issues related to team familiarity and note that the literature shows stable teams have shorter OR times, fewer surgical flow disruptions, higher satisfaction, and more trust. They note that team stability helps in recognition of non-verbal communication and anticipation of others’ activities. Team stability applies not only to scheduling cases with stable personnel but also ensuring, within feasible limits, that the same personnel are present through the whole case.


They have an excellent discussion on preoperative briefings. They cite their own experience and that from the literature, which demonstrate such preoperative briefings reduce the number of surgical flow disruptions and miscommunications per case, trips out of the OR, staff turnover and wrong-site surgeries and increase staff satisfaction and perception of safety culture.


Their discussion of tools and technology focuses on the need to involve all the OR personnel in the design and planning for implementation of new technologies so that usability and workflow factors are considered and unintended consequences might be anticipated. They note how something seemingly benign may eliminate desirable functions. One example they give is how electronic whiteboards might eliminate the social and teambuilding functions that the old whiteboards provided. They encourage basic usability assessment for any new technologic introduction and recommend simulation testing where possible.


They have a good section on standardized procedures and checklists. On the latter they note the importance of good checklist design and identifying where checklists are truly needed, so we’re not just adding on layers of complexity or additional burdens. They note that “checklist fatigue” can lead to teams performing the checklist in a perfunctory manner, defeating the purpose for which good checklists are designed.


Lastly, they discuss the importance of developing a culture of safety. This includes leadership engagement (for example, doing regular executive walkrounds and engaging involved staff in discussions on safety), the role of the surgeon, the recognition that errors occur and we need to identify them and mitigate their effects, and the importance of teamwork.


An article by Cooper and Makary (Cooper 2012) on the comprehensive unit-based safety programs (CUSP’s) made famous at Johns Hopkins describes the regular meetings by both members of frontline staff and representatives from administration to discuss issues related to patient safety. Assessment of the culture of safety, including tools such as the Safety Attitudes Questionnaire (SAQ), physician champions, and teamwork training are important components. They also have a good section on both preoperative briefings and postoperative debriefings. At the preoperative briefings, staff can become familiar with others (if not already familiar) and patient/procedure can be confirmed, and discussion can include things like use/timing of antibiotics, critical steps of the case, and potential problems. In addition to the benefits mentioned above, they note that preoperative briefings have also been demonstrated to identify equipment problems earlier, reduce OR delays, and reduce OR costs. The postoperative debriefings can include discussions about what went well, what went wrong, and what could have been done better. They can also include verification of needle and instrument counts and confirmation of correct labeling of OR specimens.


Harry Sax (Sax 2012) provides insight into what it takes to develop high-performing teams, noting how the traditional surgical training programs tend to be at odds with what is needed for good teamwork. The focus of team building is on creation of a shared vision and mission, clear and achievable goals, ensuring desire to work with others to achieve those goals, recognizing the value of all team members (including making sure that all team members recognize their own value), and rewarding desirable team behavior. He provides a good discussion on the challenges of team building in the OR: differing motivations, distractions (production pressures, outside responsibilities, etc.), fact that we tend to reward for individual accomplishments rather than team accomplishments, problems with the hierarchy, and attitude that perfection is assumed. He provides solid common-sense advice on buiding teams, including how to bring new people onto teams, aligning incentives correctly (so we don’t “reward” staff for being efficient by making them do additional work uncompensated), ensuring multidisciplinary input and discussion at morbidity and mortality conferences, embracing informal leaders, soliciting feedback and suggestions from all staff, and rapidly addressing disruptive behavior by staff at all levels. His advice “hire for attitude, train for aptitude” rings true. And he notes that commitment from leadership is critical, not only for providing resources but also for promptly addressing issues as they arise.


An article on surgeon’s non-technical skills (Yule 2012) provides excellent insight into key skills such as situational awareness, decision-making, leadership, communication and teamwork. We’ll be discussing the issue of non-technical skills and their impact on surgery in a future column. There is even an article on how unconscious biases may impact patient safety and outcomes (Santry 2012).


There are two papers on root cause analyses (RCA’s) in healthcare. Karl and Karl (Karl 2012) present a hypothetical poorly done (but unfortunately typical) RCA from healthcare and compare it to one done by the NTSB on an airline accident. They discuss the appropriate way to do RCA’s, focusing on system errors and contributing factors with the goal of fixing those and preventing future occurrences. Cassin and Barach (Cassin 2012) discuss the limitations of RCA’s.


This issue also has many other good articles on various aspects of patient safety in surgery, including a good article on disclosure and apology (Eaves-Leanos 2012).






Surgical Clinics of North America. Patient Safety. February 2012




Sanchez JA, Barach PR. High Reliability Organizations and Surgical Microsystems: Re-engineering Surgical Care. Surgical Clinics of North America 2012; 92(1): 1-14




ElBardissi AW, Sundt TM. Human Factors and Operating Room Safety. Surgical Clinics of North America 2012; 92(1): 21-35




Cooper M, Makary MA. A Comprehensive Unit-Based Safety Program (CUSP) in Surgery: Improving Quality Through Transparency. Surgical Clinics of North America 2012; 92(1): 51-63




Sax H. Building High-Performance Teams in the Operating Room. Surgical Clinics of North America 2012; 92(1): 15-19




Yule S, Paterson-Brown S. Surgeons’ Non-technical Skills. Surgical Clinics of North America 2012; 92(1): 37-50




Karl R, Karl MC. Adverse Events: Root Causes and Latent Factors. Surgical Clinics of North America 2012; 92(1): 89-100




Cassin BR, Barach PR. Making Sense of Root Cause Analysis Investigations of Surgery-Related Adverse Events. Surgical Clinics of North America 2012; 92(1): 101-115




Santry HP, Wren SM. The Role of Unconscious Bias in Surgical Safety and Outcomes. Surgical Clinics of North America 2012; 92(1): 137-151




Eaves-Leanos A, Dunn EJ. Open Disclosure of Adverse Events: Transparency and Safety in Health Care. Surgical Clinics of North America 2012; 92(1): 163-177

















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