Elsevier

Surgery

Volume 139, Issue 2, February 2006, Pages 159-173
Surgery

Original communication
A prospective study of patient safety in the operating room

https://doi.org/10.1016/j.surg.2005.07.037Get rights and content

Background

To better understand the operating room as a system and to identify system features that influence patient safety, we performed an analysis of operating room patient care using a prospective observational technique.

Methods

A multidisciplinary team comprised of human factors experts and surgeons conducted prospective observations of 10 complex general surgery cases in an academic hospital. Minute-to-minute observations were recorded in the field, and later coded and analyzed. A qualitative analysis first identified major system features that influenced team performance and patient safety. A quantitative analysis of factors related to these systems features followed. In addition, safety-compromising events were identified and analyzed for contributing and compensatory factors.

Results

Problems in communication and information flow, and workload and competing tasks were found to have measurable negative impact on team performance and patient safety in all 10 cases. In particular, the counting protocol was found to significantly compromise case progression and patient safety. We identified 11 events that potentially compromised patient safety, allowing us to identify recurring factors that contributed to or mitigated the overall effect on the patient's outcome.

Conclusions

This study demonstrates the role of prospective observational methods in exposing critical system features that influence patient safety and that can be the targets for patient safety initiatives. Communication breakdown and information loss, as well as increased workload and competing tasks, pose the greatest threats to 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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    Supported by the directors of Controlled Risk Insurance Company (CRICO), professional liability insurance provider to Harvard Medical institutions and physicians.

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