Original communicationA prospective study of patient safety in the operating room
Section snippets
Methods
A discussion of the methodology can be found in more detail in a separate publication.31
Case overview
Of the 10 cases observed, 9 were completed; observations are included for the preoperative, intraoperative, and postoperative phases. Mean case duration was 4 hours 27 minutes (range, 2:02-9:33). One case was terminated by the surgeon during the preoperative phase, restricting observations to just this phase. Sixty-three hours of observation yielded over 4500 observations that were analyzed subsequently.
Safety-influencing system features
Qualitatively, 2 system features were identified that significantly influenced case
Discussion
In this study, we preformed a prospective observational field study of a specific health care microsystem: the OR. The goal was to identify specific system features that negatively influence provider performance and patient safety and that could be the basis for further controlled investigation and quality improvement initiatives. Across all cases, we identified frequent system-based factors that changed the expected course of care and often compromised patient safety. These factors related to
Conclusion
This study describes 2 areas that can compromise patient safety and need to be the focus of future controlled studies and patient safety initiatives: (1) communication breakdown and information loss and (2) high workload and multiple competing tasks. In addition, we have illustrated the importance of direct field observation in the study of patient safety. Through such prospective studies, we can gain a deeper understanding of complex medical environments and the processes by which care is
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