Remedy for Wrong-Site Surgery

A new study suggests that hospital policies call for a brief operating room (OR) personnel meeting before an operation to decrease surgical errors.

Researchers at Johns Hopkins Hospital (Baltimore, MD, USA) developed a standardized OR briefing program that became hospital policy in June 2006. The briefing consists of a two-minute meeting during which all members of the OR team state their name and role, and the lead surgeon identifies and verifies such critical components of the operation as the patient's identity, the surgical site, and other patient safety concerns. The briefing is performed after anesthesia is administered and prior to incision.

The researchers conducted a survey among 147 surgeons, 59 anesthesiologists, 187 nurses, and 29 other OR staff twice - once before implementing the policy and once after it had been in effect for three months. After training, a 13.2% increase in those who believed the policy would be effective was recorded among the OR personnel. And more than 90% agreed that a team discussion before a surgical procedure is important for patient safety. The study appears in the February 2007 issue of the Journal of the
American College of Surgeons.

"Although we lack systems for uniform reporting of wrong-site surgeries to understand the extent of the problem, we observed team meetings increase the awareness of OR personnel with regard to the site and procedure and their perceptions of operating rooms safety,” said lead author Martin Makary, M.D., M.P.H., director of the Johns Hopkins center for surgical outcomes research.

The briefing program is based on a similar questionnaire designed by the airline
industry to assess programs designed to reduce safety errors, and was developed following a mandate of The Joint Commission (Oakbrook Terrace, IL, USA), which evaluates and accredits nearly 15,000 health care organizations and programs in the United States. The mandate requires hospitals to have a pre-surgical conversation in the OR before every surgery, after identifying communication breakdowns as the most common root cause of wrong-site surgeries.



Related Links:
Johns Hopkins Hospital
The Joint Commission