Lingard et al reports the results of a 13 month prospective study on the occurrence of “communication failures” in which data collected prior to an intervention was compared to data obtained post intervention. Communication failures were defined as situations in which communication occurred too late, had inaccurate content, failed to achieve its purpose or excluded relevant team members as observed by a trained 3rd party observer who was in the operating room during the case. The immediate consequence (if any) of each communication failure was also recorded from a list that included: inefficiency, increased team tension, resource waste, workaround, delay, patient inconvenience, and procedural error. The study took place at a Canadian academic tertiary care hospital and the study subjects were the OR teams made up of combinations from a pool of 11 general surgeons, 24 surgical trainees, 41 OR nurses, 28 anesthesiologists, and 24 anesthesia trainees. All general elective general surgery cases done during the study period were eligible and the patients were approached for consent at least 2 days before their scheduled surgery. There was a 5 month pre-intervention data collection period, a 3 month intervention implementation period (data not used) which was followed by a 5 month post intervention period of data collection. The intervention was the introduction of a self developed, validated checklist the completion of which was the focus of a pre-operative briefing led by the surgeon and attended by the nurses, anesthesiologists and trainees who would be participating in the case. The check list covered issues related to patient information such as the diagnosis, allergies, presence of key tests and consultation; and operative issues such at the operative plan, antibiotics, anticoagulants, anesthesia requirements, special instruments, etc. (see Lingard et al, 2005 for the details of the check list development and a copy of the check list). RESULTS: During the intervention and post intervention phases of the study 302 check list briefings were completed. Most briefings lasted 1 – 4 minutes. 42% of the briefings took place prior to induction of anesthesia and 47% afterwards (for 11% the time of the briefing could not be determined). One hundred and seventy procedures were observed (86 pre-intervention and 86 post-intervention). The number of communication failures fell from 3.95 per procedure pre-intervention to 1.31 after the intervention (p<.001). The number of communication failures that were associated with at least 1 visible negative consequence fell by 64% (207 before introduction of the checklist briefing to 75 afterwards). In about 33% of the briefings the information exchanged led to the identification of a problem, a critical knowledge gap, led to a change in plan, or prompted a follow up action. A participant follow up led to the following observations: 92% agreed that the briefing allowed the team to identify and resolve problems, 88% agreed that it helped guard against mistakes and 62% agreed that the briefings were worthwhile overall. According to the authors the check list approach requires less training time than approaches such as crew resource management training and does not require the provision of significant non OR training time. The authors note that they encountered significant recurrent, cultural barriers to the implementation of their check list briefing. They note that all three OR professions (surgery, nursing, and anesthesia) are accustomed to thinking and working independently; they embrace the notion of individual excellence; and they are overwhelmed by chronic staff shortages, educational duties, and economic pressures. Each of these barriers threatens the consistent utilization of a new communication routine like the pre operative checklist guided briefing. For instance, team members may be reluctant to alter their habitual workflow to gather for a briefing, or they may resist the briefing because ‘if everyone knew what they were doing we wouldn’t have to do this,’ and they may necessarily prioritize other duties in their multitasking list. The authors cite Amalberti et al who wrote that historical and cultural precedents and beliefs that are linked to performance autonomy may pose the greatest threat to improved safety.
Refs: 1) Lingard L et al: Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg 2008;143:12-17; 2) Lingard L et al: Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR. Qual Saf Health Care 2005:14:340-346; 3) Amalberti R et al: Five barriers to achieving ultrasafe health care. Ann Intern Med 2005;142:756-764.
David S. Smith, M.D., Ph.D.