Portal de Periódicos da CAPES

Changing Culture

2010; Elsevier BV; Volume: 137; Issue: 2 Linguagem: Inglês

10.1378/chest.09-1176

1931-3543

Douglas A. Wiegmann, William F. Dunn,

Healthcare Quality and Management

In this issue of CHEST (see page 443), Einav and colleagues1Einav Y Gopher D Kara I et al.Preoperative briefing in the operating room; shared cognition, teamwork, and patient safety.Chest. 2010; 137: 443-449Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar report the results of a study on preoperative briefings and patient care during gynecologic and orthopedic surgery. The findings of this study are important, not only because they indicate that preoperative briefings can reduce nonroutine events during surgery, but because they represent a prevailing shift in how human error and patient safety are viewed within many surgical specialties as well as the health-care community in general. Traditionally, surgical outcomes have been attributed primarily to the technical skills of the individual surgeon. For example, within most surgical specialties, the primacy of technical skill is the underlying assumption driving rankings of surgical performance across institutions or among one's surgical colleagues. In general, “once patient outcomes (usually mortality) have been adjusted for patient risk factors, the remaining variance is presumed to be explained by individual surgical skill.”2Vincent C Moorthy K Sarker SK Chang A Darzi AW Systems approaches to surgical quality and safety: from concept to measurement.Ann Surg. 2004; 239: 475-482Crossref PubMed Scopus (357) Google Scholar Hence, when things go wrong or errors are made, it is logical from this perspective to naturally question the particular competency or aptitude of the individual surgeon. Indeed, such an individual-focused vs system-focused responsibility structure is endemic across medical and surgical specialties. In contrast to this historical viewpoint, Einav's research team has adopted a system safety perspective that considers human error as being caused by a combination of work-system factors rather than solely by the ability of the individual surgeon. Such factors affecting performance and outcomes include teamwork and communication, the physical work environment, technology and tool design, task and workload factors, and organizational variables. From a system safety perspective, therefore, patient safety programs are likely to be most effective when they intervene at specific failure points within a process or organization rather than when they focus exclusively on the competency of the individual who committed an error.3Carthey J de Leval MR Reason JT The human factor in cardiac surgery: errors and near misses in a high technology medical domain.Ann Thorac Surg. 2001; 72: 300-305Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar The study conducted by Einav and colleagues addresses a work-system factor that is perhaps one of the most difficult to improve, namely, teamwork. Indeed, the multidisciplinary nature of teams in many health-care settings poses a challenge to those aiming to optimize performance and improve patient care.4Healey AN Sevdalis N Vincent CA Measuring intra-operative interference from distraction and interruption observed in the operating theatre.Ergonomics. 2006; 49: 589-604Crossref PubMed Scopus (251) Google Scholar In particular, teamwork in health care can often involve collaboration among a myriad of health-care specialties, including attending physicians, residents, nurses, technicians, and other associated personnel. Team members are jointly responsible for patient care, yet at the same time they have a wide variety of different tasks to perform. Furthermore, different tasks and activities among the team may interfere with one another such that the conditions necessary for the successful execution of a task by one team member may hinder or delay the actions of others on the team. Compounding the problem is the fact that there are numerous forms of distraction and interruption within health-care settings that can interfere with a team's ability to effectively communicate and coordinate these activities. Therefore, it is often difficult for diverse health-care teams to develop familiarity, trust, and a common understanding of patient needs and then effectively coordinate their activities to achieve safe and effective patient care. Not surprising, the Joint Commission on Health Care Quality and Safety5Joint Commission on Health Care Quality and Safety Sentinel event statistics.http://www.jointcommission.org/SentinelEvents/Statistics/Google Scholar reports “communication” as the number one root cause (65%) of reported sentinel events. Preoperative briefings or “team huddles” have been used as an intervention to improve teamwork and safety in a variety of high-risk industries (eg, aviation and nuclear power) as well as across multiple health-care settings, including surgery. Of note, preoperative briefings in surgery are not synonymous with the universal protocol or presurgical pause to ensure the right patient, right site, and right procedure. Rather, briefings involve a more in-depth review of the case, such as other significant patient background information, needed equipment, and any nuances of the planned surgery. Briefings also allow team members to ask questions or clarify uncertainties. Thus, briefings in general can be beneficial for all types of health-care teams in terms of planning different aspects of patient care, but may be particularly beneficial for unfamiliar teams who may not be acquainted with specific procedures or processes followed by an individual physician or surgeon. The findings of the study by Einav's research team are quite clear. They found a 25% reduction in the average number of nonroutine events that occurred within surgical cases and a significant increase in the number of surgical cases in which no nonroutine events occurred. These results are similar to those reported by DeFontes and Surbida,6DeFontes J Surbida S Preoperative safety briefing project.Permanente J. 2004; 8: 21-27PubMed Google Scholar who developed a preoperative briefing protocol for use by general surgical teams that was similar to a preflight briefing used by the airline industry. A 6-month pilot of the briefing protocol indicated a significant reduction in wrong-site surgeries. Within cardiac surgery, our research team has observed significant reductions in the frequency of nonroutine events postimplementation of preoperative briefings.7Henrickson SE Wadhera RK Elbardissi AW Wiegmann DA Sundt III, TM Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery.J Am Coll Surg. 2009; 208: 1115-1123Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar Similar findings were also recently observed within the context of laparoscopic surgery.8Lingard 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. 2008; 143: 12-17Crossref PubMed Scopus (446) Google Scholar These studies1Einav Y Gopher D Kara I et al.Preoperative briefing in the operating room; shared cognition, teamwork, and patient safety.Chest. 2010; 137: 443-449Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar, 2Vincent C Moorthy K Sarker SK Chang A Darzi AW Systems approaches to surgical quality and safety: from concept to measurement.Ann Surg. 2004; 239: 475-482Crossref PubMed Scopus (357) Google Scholar, 3Carthey J de Leval MR Reason JT The human factor in cardiac surgery: errors and near misses in a high technology medical domain.Ann Thorac Surg. 2001; 72: 300-305Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar, 4Healey AN Sevdalis N Vincent CA Measuring intra-operative interference from distraction and interruption observed in the operating theatre.Ergonomics. 2006; 49: 589-604Crossref PubMed Scopus (251) Google Scholar, 5Joint Commission on Health Care Quality and Safety Sentinel event statistics.http://www.jointcommission.org/SentinelEvents/Statistics/Google Scholar, 6DeFontes J Surbida S Preoperative safety briefing project.Permanente J. 2004; 8: 21-27PubMed Google Scholar, 7Henrickson SE Wadhera RK Elbardissi AW Wiegmann DA Sundt III, TM Development and pilot evaluation of a preoperative briefing protocol for cardiovascular surgery.J Am Coll Surg. 2009; 208: 1115-1123Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar are also important because they represent the beginnings of a shift in culture with regard to how errors are perceived. For example, Einav and colleagues do not seek to blame individuals for not communicating, they do not focus on stereotypes about the “strong and overbearing” personalities of surgeons, nor do they foster the traditional viewpoint that the surgeon is the “captain and commander of the ship” and all other surgical personnel are simply support staff who do not directly contribute to the quality of patient care. Rather, their study focuses on developing tools and processes for improving teamwork and communication in order to reduce the likelihood of work-system failures (nonroutine events) such as inaccurate or missing information, improperly assembled or broken equipment, or a lack of coordination of individual activities that can impact performance and patient safety. Furthermore, this shift in culture is not limited to surgery or to the use of preoperative briefings. Other techniques for improving work-system factors such as standardizing procedures, using checklists, and incorporating new information technology are all methods that are being adopted across a variety of medical settings to improve performance and patient safety.9Carayon P Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. Erlbaum, Hillsdale, NJ2007Google Scholar Fundamental to the synthesis of both personal and system responsibility (and accountability) when errors occur is the need for a classification system pertaining to error analysis. Within the aviation industry, the Human Factors Analysis and Classification System10Wiegmann DA Shappell SA Human Error Approach to Aviation Accident Analysis: The Human Factors Analysis and Classification System. Ashgate Press, Burlington, VT2003Google Scholar was created in order to provide a standardized approach to assessment of aviation accident reporting, based on the Swiss cheese model of latent error prevention espoused by James Reason.11Reason JT A system approach to organizational error.Ergonomics. 1995; 38: 1708-1721Crossref Scopus (243) Google Scholar, 12Reason JT Human error: models and management.BMJ. 2000; 320: 768-770Crossref PubMed Scopus (3572) Google Scholar Within this system, a classification system was created to accommodate empirical data of causes of aviation mishaps. Categories, including unsafe acts, preconditions for unsafe acts, unsafe supervision, and organizational influences, appear to have significant potential for transfer into systems of medical safety analysis. Notwithstanding this optimism, changes in culture have been slow going. For example, despite the potential benefits of preoperative briefings and the recent endorsement of briefings by the World Health Organization,13World Health Organization's patient-safety checklist for surgery.Lancet. 2008; 372: 1148-1149PubMed Google Scholar their utilization remains relatively low within many surgical specialties. This sluggishness of change is due to many reasons. One such reason is that physicians and other health-care providers are often not convinced that incorporating work-system tools and processes into their practice (eg, briefings or checklists) will have a significant enough impact on patient care to make changing their ways worth their effort. Simply telling them that such changes are in the “best interest of their patients” will not suffice. In this day and age of evidence-based medicine, physicians want proof in the form of hard data to back up claims regarding any intervention. Admittedly, evidence for the effectiveness of many work-system interventions has historically been generalized from other industries outside of health care, or it has been anecdotal and subjective. Only more recently have studies such as the one reported by Einav and colleagues begun to provide empirical and tangible support indicating that changes in work-system variables can reduce nonroutine events associated with patient safety. However, more research needs to be done in this area. A second reason why change has been slow going is that there are few generic tools for addressing work-system factors; consequently, a considerable amount of time and effort is often needed to develop effective tools, processes, and technologies. Furthermore, if not well designed, these changes can cause more problems than they solve. For example, there are no standardized protocols for conducting preoperative briefings. Each surgical specialty has unique “issues” that may need to be addressed prior to each operation. Therefore, a generic off-the-shelf checklist may not suffice. This is not to say that the development of a common template for designing briefing protocols is unattainable; rather, the specific content needs to be tailored to each surgical specialty. As documented by DeFontes and Surbida,5Joint Commission on Health Care Quality and Safety Sentinel event statistics.http://www.jointcommission.org/SentinelEvents/Statistics/Google Scholar the successful development of a preoperative briefing protocol takes several months of research and development, beginning with understanding the needs and views of key stakeholders and the nuances of the organization in which such briefings are to take place. Consequently, considerable research needs to be done to develop effective work-system interventions. To some readers, the issues presented here may seem noncontroversial or even commonsensical. Yet, there remain many health-care organizations in which errors are not reported for fear of negative repercussions, nurses are rebuffed by physicians for speaking up about potential patient safety issues, personnel in the quality office are viewed as adversaries, and surgeons do not want to take 5 min to meet with their team prior to surgery. Changes in culture will take time. However, as more empirical studies such as that by Einav and colleagues get published, the idea that changes in work-system factors is a better way to improve patient safety will continue to grow throughout the entire health-care community. Only then, perhaps, will the culture of simply shaming individuals for their mistakes as a strategy for improving patient care be no more. Preoperative Briefing in the Operating Room: Shared Cognition, Teamwork, and Patient SafetyCHESTVol. 137Issue 2PreviewContemporary preoperative team briefings conducted to improve patient safety focus mainly on supplying identification details regarding the patient and the surgical procedure. Drawing on cognitive theory principles, in this study a briefing protocol was developed that presents a broader perspective model of the patient and the planned procedure. In addition to customary identification details and drug sensitivities, the new briefing also includes review of significant background information, needed equipment, planned surgery stages, and so forth. Full-Text PDF