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Operating Room Briefings and Wrong-Site Surgery

Martin A Makary, MD, MPH, Arnab Mukherjee, BA, J Bryan Sexton, PhD, Dora Syin, BS, Emmanuelle Goodrich, MPH, Emily Hartmann, MSS, Lisa Rowen, RN, DScN, Drew C Behrens, Michael Marohn, DO, FACS, Peter J Pronovost, MD, PhD

Wrong-site surgery can be a catastrophic event for a patient, caregiver, and institution. Although communication breakdowns have been identified as the leading cause of wrong-site surgery, the efficacy of preventive strategies remains unknown. This study evaluated the impact of operating room briefings on coordination of care and risk for wrong-site surgery. STUDY DESIGN: We administered a case-based version of the Safety Attitudes Questionnaire (SAQ) to operating room (OR) staff at an academic medical center, before and after initiation of an OR briefing program. Items questioned overall coordination and awareness of the surgical site. Response options ranged from 1 (disagree strongly) to 5 (agree strongly). MANOVA was used to compare caregiver assessments before and after the implementation of briefings, and the percentage of OR staff agreeing or disagreeing with each question was reported. RESULTS: The prebriefing response rate was 85% (306 of 360 respondents), and the postbriefing response rate was 75% (116 of 154). Respondents included surgeons (34.9%), anesthesiologists (14.0%), and nurses (44.4%). Briefings were associated with caregiver perceptions of reduced risk for wrong-site surgery and improved collaboration [F (6,390) 10.15, p 0.001]. Operating room caregiver assessments of briefing and wrong-site surgery issues improved for 5 of 6 items, eg, "Surgery and anesthesia worked together as a well-coordinated team" (67.9% agreed prebriefing, 91.5% agreed postbriefing, p 0.0001), and "A preoperative discussion increased my awareness of the surgical site and side being operated on" (52.4% agreed prebriefing, 64.4% agreed postbriefing, p 0.001). CONCLUSIONS: OR briefings significantly reduce perceived risk for wrong-site surgery and improve perceived collaboration among OR personnel. (J Am Coll Surg 2007;204:236­243. © 2007 by the American College of Surgeons)

BACKGROUND:

Cases of wrong-site surgery have gained considerable attention recently, and can be extraordinarily devastating to patients, families, caregivers, and institutions.1,2 Wrong-site, wrong-procedure, and wrong-patient operCompeting Interests Declared: None. Received August 8, 2006; Revised October 4, 2006; Accepted October 18, 2006. From the Departments of Surgery (Makary, Marohn, Pronovost) and Anesthesiology (Sexton, Pronovost), Johns Hopkins University School of Medicine (Makary, Syin, Goodrich, Marohn, Pronovost); the Department of Health Policy and Management (Makary, Pronovost), Johns Hopkins Bloomberg School of Public Health; the Department of Nursing (Rowen, Pronovost), Johns Hopkins University School of Nursing; Center for Surgical Outcomes Research (Makary, Mukherjee, Sexton), and the Johns Hopkins Quality and Safety Research Group (Mukherjee, Syin, Behrens, Pronovost), Johns Hopkins Medical Institutions, Baltimore, MD; Yale University School of Medicine (Mukherjee) and Yale University School of Management, New Haven, CT; Columbia University (Behrens), New York, NY; and Georgetown University School of Medicine (Hartmann), Washington, DC. Correspondence address: Martin A Makary, MD, MPH, Johns Hopkins University School of Medicine, Johns Hopkins Medical Institutions, 600 N Wolfe St, Carnegie 683, Baltimore, MD 21224.

ations often occur because of failures in communication and collaboration.3,4 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) identified communication breakdowns as the most common root cause of wrong-site operations and of operative and postoperative events in 2005.5 The use of briefings as structured coordination opportunities has garnered a lot of attention in recent years, yet we know surprisingly little about operating room (OR) briefings as a means to decrease the risk of wrong-site operations. Fortunately, wrong-site surgery is relatively rare, but its low frequency makes it logistically difficult to evaluate the effectiveness of interventions designed to prevent wrong-site surgery.6 A logical surrogate measure to evaluate the impact of interventions to reduce wrong-site surgery is to use caregiver assessments of briefings and their perceived risk for these events. Coordination of care activities in the OR is highly variable among hospitals and among caregiver roles within an OR, and obser-

© 2007 by the American College of Surgeons Published by Elsevier Inc.

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Operating Room Briefing Assessment Tool

Abbreviations and Acronyms

OR ORBAT SAQ

operating room Operating Room Briefing Assessment Tool Safety Attitudes Questionnaire

vational data indicate that there is a lack of discussion and planning before skin incision.7-9 Recent evidence suggests that there is significant value in conducting a preoperative discussion just before skin incision at the time of a surgical "time-out" to briefly review the names and roles of all team members, the operative plan, the familiarity with the procedure, and potential issues for the patient.10 The aim of this study was to measure the association between OR briefings and clinician perceptions of collaboration and perception of risk for wrongsite surgery. METHODS

Study design and study population

Survey questions were developed by generating a casebased version of the SAQ teamwork and patient safetyrelated items, which we have found to be associated with outcomes and error rates.6,9 The 17-question survey consisted of questions relating to the awareness and understanding of the surgical site, willingness to speak up when problems were perceived, and the quality of teamwork and communication between caregivers in the OR. Response options for each item ranged from 1 (disagree strongly) to 5 (agree strongly). The dependent variables were six survey questions related to briefings and wrongsite operations: 1) "A preoperative discussion increased my awareness of the surgical site and side being operated on"; 2) "The surgical site of the operation was clear to me before the incision"; 3) "A team discussion before a surgical procedure is important for patient safety"; 4) "Team discussions are common in the ORs here"; 5) "Decision making used input from relevant personnel"; and 6) "Surgery and anesthesia worked together as a well-coordinated team."

The briefing program

We used a pre- and postdesign in which we measured perceptions of briefings and awareness of the surgical site and side for 5 months: we implemented OR briefings for 3 months and then measured collaboration and awareness of surgical site and side for 2 months. We used a case-based version of the Safety Attitudes Questionnaire (SAQ, OR version) called the OR Briefing Assessment Tool (ORBAT), starting in May 2005. To assess OR briefings, we surveyed caregivers as they exited their first case of the day to capture the effectiveness of care coordination and wrong-site surgery prevention during that case. The study site included the general operating rooms in an academic medical center. There were 11 surgeons (7 general surgeons, 2 plastic surgeons, and 2 neurosurgeons) who agreed to implement briefings after 2 months of baseline data collection. A case-based OR SAQ was administered to OR staff, including physicians and nurses, at an academic medical center for 2 months before initiation of an OR briefing program. Sampling was not used because of small sample sizes of diverse caregiver roles in the OR, which would threaten the generalizability of the data. Instead, a high response rate was sought to capture the representative perceptions of each caregiver type in the OR.

The OR briefing is a tool to enhance communication among the OR team members and improve patient safety. Our 2-minute OR briefing includes 3 critical components: each member of the OR team states his or her name and role, the surgeon leads the "time-out," as required by the Joint Commission on Accreditation of Healthcare Organizations to identify critical components of the operation, including surgical site, and the care teams discuss and mitigate potential safety hazards11-13 (Fig. 1). The staff was trained to perform the briefing after anesthesia was achieved and before incision. We administered the ORBAT 2 months before implementing briefings through the 11 participating surgeons, allowed surgeons to practice briefings for 3 months, and then administered the ORBAT for 2 months of postintervention data. At the beginning of the intervention period, all OR staff were trained through in-service training sessions using a standardized format previously described (Fig. 1) to perform and participate in OR briefings.11 Training sessions were conducted at the surgical faculty meeting, a departmentwide staff meeting, and a nursing administration meeting for all OR nurses and technicians. One of the authors, who is a surgeon (MAM), also met individually

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Figure 1. Operating room briefing checklist.

with each surgeon in the program. An independent study coordinator visited each operation to evaluate compliance with briefings in the OR during the study period. The coordinator reviewed the elements of the briefing with the attending surgeon before each operation and observed the beginning of the operation. The OR briefing protocol was completed in all cases. The coordinator subsequently returned at the end of the operation to administer and collect the surveys and compiled qualitative formative feedback from the staff, so that future briefing checklists could be developed.

Statistical analysis

tistical analyses were performed using SPSS version 13.0 (SPSS Inc). RESULTS The prebriefing ORBAT response rate was 85% (306 of 360 respondents), and the postbriefing response rate was 75% (116 of 154). There were 422 total respondents, including surgical attending physicians (20.4%), surgical residents (14.5%), anesthesia attending physicians (9.5%), anesthesia residents (4.5%), certified registered nurse anesthetists (8.1%), scrub nurses (17.3%), circulating nurses (19%), medical students (3.8%), nurse assistants (1.0%), and "other" (2.0%) (Table 1). MANOVA of the six items yielded a significant omnibus F result. An omnibus F to test for changes in caregiver assessments, F (6,390) 10.15, p 0.001, indicated that OR caregivers assessed briefings and wrong-site surgery-related issues differently after the briefing intervention. OR caregiver assessments of

Using MANOVA, we tested for pre- and postdifferences in responses to the six briefing and wrong-site surgery items on the ORBAT survey instrument. In addition to the response means compared with MANOVA, we also reported the percent agreement (agree slightly plus agree strongly) for items pre- and post-OR briefings. All sta-

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Table 1. Respondent Characteristics

Respondent type n %

Attending surgeon Surgical resident Attending anesthesiologist Anesthesiology resident Certified registered nurse anesthetist Scrub nurse Circulating nurse Nurse assistant/physician assistant Medical student Other/missing Total

86 61 40 19 34 73 80 6 16 7 422

20 15 10 5 8 17 19 1 4 1 100.0

dence intervals for each of the six items' pre- and post-groups, and Figure 2 presents the percent agreement and percent disagreement for each item pre- and postintervention. DISCUSSION Although events like wrong-site surgery are far too rare to measure as rates, health-care organizations need a viable method to evaluate the effectiveness of their safety interventions.14 In this study, we found evidence that using OR briefings significantly reduces uncertainty about the location of the surgical site among OR caregivers. In addition, we found OR briefings to be an effective tool in promoting teamwork between anesthesia and surgery staff members and in more fully using input from relevant caregivers for decision making in the OR. Briefings can have a significant impact on improving care coordination and reducing the risk of wrongsite operations in the OR, and the ORBAT may serve as a valuable tool to evaluate the effectiveness of interventions to improve patient safety and collaboration in the OR.

Conceptual model for preventing harm

briefing and wrong-site surgery issues improved for five of the six items: "A preoperative discussion increased my awareness of the surgical site and side being operated on" (52.4% agreed pre, 64.4% agreed post); "The surgical site of the operation was clear to me before the incision" (88.2% agreed pre, 96.6% agreed post); "Surgery and anesthesia worked together as a well-coordinated team" (67.9% agreed pre, 91.5% agreed post); "Decision making utilized input from relevant personnel" (78.7% agreed pre, 89.6% agreed post); "Team discussions are common in the ORs here" (37.4% agreed pre, 48.3% agreed post). The only item that did not improve was, "A team discussion before a surgical procedure is important for patient safety," for which responses were favorable both pre- and postintervention (94.0% versus 93.3%, respectively). Table 2 presents the means and confi-

Given the relative infrequency of wrong-site operations, how can we evaluate progress toward reducing the risk for their occurrence? One approach is to use an education model in which knowledge leads to changes in attitudes, which, in turn, changes behavior

Table 2. Operating Room Briefing Assessment Tool Briefing and Wrong-Site Surgery Item Descriptive Statistics

Prebriefing 95% CI for mean (lower bound­ upper bound) Postbriefing 95% CI for mean (lower bound­ upper bound)

Query

Univariate F (p value)

Mean

Mean

A preoperative discussion increased my awareness of the surgical site and side being operated on The surgical site of the operation was clear to me before the incision Decision making utilized input from relevant personnel Surgery and anesthesia worked together as a well-coordinated team A team discussion before a surgical procedure is important for patient safety Team discussions are common in the ORs here

12.275 (p 9.864 (p 8.858 (p 52.253 (p 2.384 (p 11.617 (p

0.001) 0.002) 0.003) 0.000) 0.123) 0.001)

3.18 4.45 4.02 3.68 4.46 2.75

(3.02­3.34) (4.34­4.56) (3.89­4.14) (3.54­3.82) (4.38­4.55) (2.61­2.90)

3.74 4.75 4.35 4.54 4.59 3.24

(3.50­3.97) (4.64­4.86) (4.19­4.50) (4.39­4.69) (4.47­4.71) (2.96­3.51)

Data represented as a mean score on a 1 to 5 scale (5, full agreement) and upper and lower 95% confidence intervals of mean scale score.

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Figure 2. Percent agreement and disagreement for each item pre- and postbriefings.

and ultimately reduces preventable harm (Fig. 3).6,15,16 Each component can be measured. Knowledge of a new practice to improve safety is an essential first step in the prevention of harm. It is important to train caregivers about implementing a new intervention and to measure the effectiveness of the training with a knowledge assessment. In this study, we used an inservice training session and knowledge assessment of

the OR briefing procedure with all OR staff before initiation of OR briefings. Knowledge of the new practice is necessary but not sufficient to change behavior. It is critical that caregivers value the intervention and perceive it to be useful or important. Using "physician champions" to facilitate development of an intervention may be one option in changing the attitudes toward safety in an

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Figure 3. A conceptual model for preventing harm.

institution. In this study, each participating surgeon was recruited as a "physician champion" to encourage communication and teamwork in the OR. Attitudes toward safety can be measured by using a metric such as the Safety Attitudes Questionnaire (SAQ) or ORspecific measures such as the ORBAT, used in this study.7 Although there is no hard evidence to suggest that a change in attitude is sustained, we have found strong support for this culture change within our institution. Many of the staff members who participated in this pilot study have incorporated briefings into their OR routines, and continue to use them in their daily practice. The protocol has been promoted by the hospital administration and has gained considerable support among other staff members. We estimate that more than half of the surgeons in our institution now use an OR briefing system, and we believe that the majority will ultimately integrate it into their practice. To assist in the process, we have taken the formative feedback provided by the study participants and developed a foundational briefing tool for universal use ("briefing 5," Fig. 4). This is designed to be a generalizable framework, which can be tailored to each surgical specialty. When knowledge and attitudes toward safety interventions are aligned, it is still important to investigate whether these translate to the adoption of desired behaviors in practice. This is generally accomplished by using observation tools that focus on behavioral markers, such as the Behavioral Marker Audit Form.17 For example, one can observe how the briefings were conducted and provide feedback to the team. Such a process, if imple-

mented at regular intervals, can provide predictable and structured feedback related to routine practice. More research is needed to further validate this model and the associated data collection methods, so that OR patient safety efforts are evidence-based and generalizable.

Limitations

We recognize that there are some important limitations to this study. First, we used caregiver assessments of issues related to briefings and wrong-site operations on the ORBAT, rather than rates of wrong-site surgery. The six items reported here may not correlate with actual wrong-site operations. But scores on the SAQ are associated with important clinical and operational outcomes in the OR.10 Second, we used a pre- and postdesign without a control group, rather than a more robust randomized design, and this could introduce bias. Because nurses and anesthesiologists work with multiple surgeons, and the intervention required training of staff, we believed a randomized design was not feasible in this early stage of the research, because teams would be contaminated with clinicians who were trained in briefings.

Figure 4. Operating room briefing 5.

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Also, it is unlikely that temporal trends in briefing and wrong-site surgery perceptions biased our results; there were no other OR patient safety interventions during the study period. Finally, we studied one academic medical center, and, as such, we do not know whether our results would apply to other settings.

Implications

Acquisition of data: Goodrich, Hartmann, Syin Analysis and interpretation of data: Mukherjee, Makary, Sexton Drafting of manuscript: Mukherjee, Markary, Sexton, Hartmann Critical revision: Pronovost, Sexton, Rowen, Goodrich, Syin, Mahron

REFERENCES 1. Kohn L, Corrigan J, Donaldson M, eds. To err is human: building a safer health system. Institute of Medicine. Washington, DC: National Academy Press; 1999. 2. Institute of Medicine. Committee on Quality of Health Care in America. Crossing the quality chasm: a new health care system for the 21st century. Washington, DC: National Academy Press; 2001. 3. Joint Commission on Accreditation of Healthcare Organizations. Sentinel events: evaluating cause and planning improvement. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 1998. 4. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: An observational classification of recurrent types and effects. Qual Saf Health Care 2004;13:330­334. 5. Saufl NM. Universal protocol for preventing wrong site, wrong procedure, wrong person surgery. J Perianesth Nurs 2004;19: 348­351. 6. Makary MA, Sexton JB, Freischlag JA, et al. Patient safety in surgery. Ann Surg 2006;243:628­632; discussion 632­635. 7. 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;202:746­752. 8. Sexton JB, Makary MA, Tersigni AR, et al. Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel. Anesthesiology 2006;105:877­884. 9. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: Cross sectional surveys. BMJ 2000;320:745­749. 10. DeFontes J, Surbida S. Preoperative safety briefing project. Permanente J 2004;8:21­27. 11. Makary MA, Holzmueller CG, Thompson D, et al. Operating room briefings: working on the same page. Jt Comm J Qual Patient Saf 2006;32:351­355. 12. Lingard L, Reznick R, DeVito I, Espin S. Forming professional identities on the health care team: Discursive constructions of the "other" in the operating room. Med Educ 2002;36:728­ 734. 13. Dwyer K. Surgery-related claims and the systems involved. J Med Pract Manage 2003;18:332­336. 14. Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Incidence, patterns, and prevention of wrong-site surgery. Arch Surg 2006;141:353­357; discussion 357­358. 15. Vincent C, Moorthy K, Sarker SK, et al. Systems approaches to surgical quality and safety: From concept to measurement. Ann Surg 2004;239:475­482. 16. Klein KJ, Kozlowski SWJ. From micro to meso: Critical steps in conceptualizing and conducting multilevel research. Organizational Research Methods 2000;3:211­236. 17. Sexton JB, Holzmueller CG, Pronovost PJ, et al. Variation in

The OR briefing as a safety initiative designed to reduce wrong-site surgery has many implications in physician and nurse training. Incorporating the OR briefing into residency training for surgery and anesthesiology residents, nursing training, and medical student training may prove beneficial in improving care coordination and reducing the incidence of wrong-site surgery. In addition, the integration of briefings into medical and nursing education may help improve the teamwork climate in operating rooms by promoting consistent and structured communication, proactive planning for potential problems, and interdisciplinary collaboration between physicians and nurses in surgery and anesthesiology. The relationship between culture change, improved coordination, and reduction of errors has been well established from research in the aviation industry.18-22 Their principles have been applied to other disciplines, including health care. This research in the aviation industry provides the framework for our study of similar safety interventions in surgery.

Future steps

In the future, we can study the impact of briefings on caregiver attitudes related to teamwork and patient safety and care coordination behaviors. Briefings may be beneficial before bedside procedures are performed in the inpatient setting, or at the start of a day or shift to proactively plan for potential problems. Briefings before procedures may also be valuable in reducing adverse events in the outpatient setting. Although briefings are not a panacea for what ails care coordination in health care, they do have the potential to fill many of the gaps created by production pressures; staffing problems; high levels of acuity; and lack of familiarity with environments, people, or procedures.

Author Contributions

Study conception and design: Makary, Pronovost, Sexton, Rowen, Marohn

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caregiver perceptions of teamwork climate in labor and delivery units. J Perinatol 2006;26:463­470. 18. Sexton JB, Klinect JR. The link between safety attitudes and observed performance in flight operations. Columbus, OH: Ohio State University; 2001 (conference proceedings). 19. Helmreich RL. On error management: lessons from aviation. BMJ 2000;320:781­785. 20. Sexton J, Thomas EJ, Helmreich RL. Error, stress and teamwork

in medicine and aviation: cross sectional surveys. BMJ 2000; 320:745­749. 21. Sexton J, Helmreich R, Williams R, et al. The Flight Management Attitudes Safety Survey (FMASS). Research Project Technical Report 01­01. Austin, TX: University of Texas, 2001. 22. Helmreich R, Foushee H, Benson R, et al. Cockpit resource management: exploring the attitude-performance linkage. Aviat Space Environ Med 1986;57:1198­1200.

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