Improving Operating Room Safety: A Success Story

Abstract

Despite the introduction of the Universal Protocol, patient safety in surgery remains a daily challenge in the operating room. This case study describes one community health system’s efforts to improve operating room safety through human factors training and ultimately the development of a surgical checklist. Using a combination of formal training, local studies documenting operating room safety issues and peer to peer mentoring we were able to substantially change the culture of our operating room. Our efforts prepared us for the successful implementation of a standardized checklist to improve operating room safety throughout our entire system. In the years that followed, the challenge shifted to maintaining our success. Cultural change is a process that takes many years and with physician and staff turnover it is easy to lose focus and slip back into old ways. We initiated a program where new physicians and staff were oriented to our operating room culture. Based on our experience we recommend a multimodal approach to improving operating room safety. Regardless of what specific measures are implemented the greatest factors that predict success are finding committed champions, both physician and OR staff, and persistently encouraging a culture of safety.KeywordsSurgical SafetySurgical ChecklistHuman FactorsCulture of SafetyPhysician engagement