Hospitals try to improve patient safety in the OR

A new quality-improvement project encourages better communication among surgical team members.

By Kevin B. O’Reilly — Posted May 8, 2006

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

Surgeons traditionally have ruled the roost in operating rooms, with the belief being that the best way to reduce errors and get superior results is to give surgeons what they want and stay out of their way.

But a group of at least two dozen hospitals met in April to explore a more collaborative approach to improving surgical care that still leaves the surgeon in charge, but creates an atmosphere where others are freer to speak up and more likely to have what they say heard.

The hospitals met in Chicago as part of Transformation of the OR, or TOR, a multiyear collaborative quality improvement project developed by VHA, an Irving, Texas-based alliance of more than 2,400 nonprofit health care organizations. A VHA survey of TOR participants found that as many as 60% of nonsurgical OR staff agreed with this statement: "In the ORs here, it is difficult to speak up if I perceive a problem with patient care."

That lack of communication can lead to adverse outcomes for patients, said Jeff Dunn, MD, senior medical director of the TOR project.

"What the surgeon usually sees as good communication is that his instructions are listened to by others," Dr. Dunn said. That approach is no longer good enough in an era when complicated laparoscopic, robotic and endovascular surgeries are becoming increasingly common, he said.

Miscommunication among colleagues is partially responsible for 44% of medical errors, according to a 2004 study in the Annals of American Family Medicine.

"One of the daunting challenges is how do you have a team of equals and still have a captain of the ship," Dr. Dunn said. "The surgeon still has to call the shots for patients, but he has to be aware of the other people in the room and assimilate what they're thinking and seeing. The process has to be open, and too often it isn't."

A new operating culture

One of TOR's goals is to change the culture of the OR by instituting a set of process changes that encourage, and even require, communication. For example, TOR participants have a white board in the OR with the name and title of each OR team member on it. Basic stuff, it would seem, but crucial to helping manage communication in a tense environment.

"It's easy to say, 'Let's communicate more,' " Dr. Dunn said. Providing the structure that allows such communication to occur, though, is the key.

In addition to the white board, the communication concepts include:

  • Preoperative timeouts to allow surgeons to explain the plan and for nurses, anesthesiologists and other staff to ask questions. These timeouts also include a checklist of measures such as appropriately administering antibiotics, dispensing deep-vein thrombosis prophylaxis and reviewing a patient's history.
  • Postoperative debriefings in which surgeons, nurses and other staff review how the surgery went.

Timeouts, as such, are not new. Beginning in July 2004 the Joint Commission on Accreditation of Healthcare Organizations asked hospitals to implement a universal protocol to reduce surgical errors by ensuring, just before surgery begins, that they are set to do the right surgery on the right body part on the right patient.

The TOR project takes things a bit further by helping participating hospitals collaborate with one another to implement the Surgical Care Improvement Project's national quality measures to reduce surgical-site infections, deep-vein thrombosis, perioperative cardiac events and postoperative pneumonia.

Benefits for surgeons

The type of structured communication TOR calls for can be helpful to the surgeon as well, according to William Mannella, MD, chair of the surgery department at Crozer-Chester Medical Center in Chester, Pa. The medical center's orthopedic surgery department is implementing the TOR concepts.

"If the surgeon forgets to order antibiotics, his failure to do that in the past has been blamed on him," Dr. Mannella said. "It was his fault; he forgot." By encouraging communication among surgical team members, now a nurse might feel freer to speak up when noticing the antibiotic was not ordered and to inquire why not, he said.

In the past, nurses might have felt intimidated by a surgeon, said Diane Wolk, RN, OR nurse manager at Crozer-Chester, a 422-bed nonprofit facility.

"Nobody wants to tell anybody what to do, but when it comes to patient care, nurses do have to speak up," she said. "Nurses are becoming braver."

The TOR project is a follow-up to VHA's earlier Transformation of the ICU project, which is ongoing and focuses on reducing ventilator-associated pneumonia and other intensive care unit safety issues. In its second year, participating hospitals saw a 41% drop in ventilator-associated pneumonias, 18% fewer ICU patient deaths and an 11% shorter hospital stay, according to VHA.

The TOR project's results aren't available yet, but Dr. Mannella said the communication process, similar to that used in aviation, can only help.

"The airline people debrief after every flight, and they've never had a perfect mission," he said. "I'm sure we've never had a perfect operation. In this business you've just got to get as close as you can. God does the rest."

Back to top



Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story

Read story


American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story

Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story

Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story

Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story

Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story

Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story

Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn