Protecting patients from an unsafe system

Abstract

Introduction Surgical teams must deal regularly with unanticipated events in the operating room (OR). We sought to understand the etiology and resolution of these events using a qualitative assessment. Methods To increase the likelihood of capturing an event, we video-recorded and transcribed 8 complex, high-acuity operations, representing 36 hours of patient care. Deviations, defined as episodes of decreased patient safety and/or delays, were identified by majority consensus of a multidisciplinary team. Factors that contributed to each event and/or mitigated its impact were determined and attributed to the system, team or individual provider. Results 24 deviations (14 safety-compromising, 5 delays, 5 both) occurred, at a rate of approximately once every 1.5 hours. All except one were compensated such that patient harm was averted. These deviations were often multifactorial (mean 2.2 factors each). As shown in the Table, problems with communication, coordination, and organizational structure (e.g. inopportunely timed hand-offs) appeared repeatedly at the root of both types of deviations. Mediation of safety compromises was most frequently accomplished with leadership and/or vigilance, while delays tended to be resolved with improved teamwork.Frequency of Appearance of the Most Common Contributing and Compensating FactorsContributing Factors% of DeviationsMitigating Factors% of DeviationsIndividual Provider(Lack of) Knowledge/Training25Monitoring/Vigilance63(Lack of) Leadership17Knowledge/Training17Decision-Making17Leadership38Team(Mis)Communication33Communication50(Mis)Coordination46Coordination33Cooperation33SystemEquipment (Failure)17--Organizational Structure29 Conclusions Unanticipated events are common in the OR. Contrary to popular belief, these events do not reflect human fallibility mitigated by a well-designed system. Rather, deviations result from poor system design and sub-optimal team dynamics, with caregivers then compensating to avoid patient harm. Such resilience has been recognized in other high-risk work environments. These results underscore the need for system redesign and improved team training to improve patient safety.