ARTICLE IN PRESS The Joint Commission Journal on Quality and Patient Safety 2017; ■■:■■–■■
Introductions During Time-outs: Do Surgical Team Members Know One Another’s Names? David J. Birnbach, MD, MPH; Lisa F. Rosen, MA; Maureen Fitzpatrick, MSN, ARNP-BC; John T. Paige, MD; Kristopher L. Arheart, EdD
Background: Introductions are the first item of the time-out in the World Health Organization Surgical Safety Checklist (SSC). It has yet to be established that surgical teams use colleagues’ names or consider the use of names important. A study was conducted to determine if using the SSC has a measurable impact on name retention and to assess if operating room (OR) personnel believe it is important to know the names of their colleagues or for their colleagues to know theirs. Methods: All OR personnel were individually interviewed at the end of 25 surgical cases in which the SSC was used. They were asked (1) to name each OR participant, and (2) if they believed it is important to know the names of their team members and (3) for their team members to know their name. Results: Of the 150 OR personnel interviewed, 147 (98%) named the surgery attending correctly. The surgery attending named only 44% of other OR staff (p < 0.001). Only 62% of the OR staff correctly named the anesthesiology attending. The anesthesiology resident was the least well known but was able to name 82% of the others. The anesthesiology attending named his or her resident 100% of the time; the surgery attending correctly named his or her resident only 68% of the time (p = 0.002). Conclusion: This study suggests that OR personnel may consider introductions to be another bureaucratic hurdle instead of the safety check they were designed to be. It appears that this first step of the time-out is often being performed perfunctorily.
he delivery of safe health care is extremely complex1 and susceptible to adverse events due to poor judgment, miscommunication, lack of compliance to protocols, and workplace inefficiencies.2 Surgical patients, in particular, may present with multiple pathologies and problems requiring input from an interprofessional health care team.3 To reduce adverse events, health care leaders have taken cues from high reliability organizations (HROs) and have begun to develop and use specialty-specific checklists.4 In fact, the use of checklists is a defining characteristic of HROs and is particularly important in high-risk, high-stress environments such as operating rooms (ORs). The World Health Organization (WHO) Surgical Safety Checklist (SSC) was devised to improve surgical outcomes and is a mainstay in more than 4,000 ORs worldwide.5,6 As specified in the SSC provided in the first edition of the WHO Guidelines for Safe Surgery,7 the preoperative briefing—the period after induction of anesthesia and before surgical incision—consists of a timeout performed in the OR. The first item reads: “Confirm all team members have introduced themselves by name and role.”7(p. 154) The effectiveness of the WHO SSC in reducing morbidity and mortality was first demonstrated in an international study in 2009 conducted by the Safe Surgery Saves Lives Study Group.8 In 2004 The Joint Commission developed the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and
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1553-7250/$-see front matter © 2017 The Joint Commission. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjq.2017.03.001
Wrong Person Surgery™ to improve surgical patient safety and reduce wrong site surgeries.9 Although the current literature offers a close examination of the importance of teamwork and communication in the OR,10–12 it does not explore how identification of name and role affects communication in the OR, nor does it validate the significance of this first step. Unfortunately, communication skills have been measured as the worst of five aspects of teamwork behavior in the OR, and deficits in patient safety are frequently a product of communication breakdowns.13 Qualitative data suggest that introductions help with the identification of roles, morale, and team performance14,15 and have been used to link teamwork and safety culture and climate with postsurgical outcomes.16 An effective briefing can be conducted in less than two minutes,17 and knowing names may greatly improve the prevention of adverse outcomes.18 Despite the use of the SSC and introductions, our experience suggests that OR team members may consider introductions to be another bureaucratic hurdle to starting a case instead of the safety check they were designed to be. The end result is that the exercise may not attain the expected results, and team members may not actually know the names of the individuals with whom they are working. The primary aim of this study was to determine if name retention occurs as a result of the time-out. A secondary aim was to assess if OR personnel believe it is important to know the names of their colleagues or for their colleagues to know theirs. We were particularly interested to see if differences existed between surgeons, anesthesiologists, and OR nurses
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David J. Birnbach, MD, MPH, et al
in this regard and how their views related to knowledge of names of those with whom they work. METHODS Setting
This study, which was conducted in July–August 2015 in the ORs of the three teaching hospitals of a large academic medical center, was approved by the Institutional Review Board, and a waiver of consent was granted. Training of Volunteers
A group of volunteers (medical students, residents, and nurses) were trained to interview participants using a standardized form. Prior to the interviews, the lead researcher [D.J.B.] trained all volunteers. In addition, he verified that a timeout was completed in each case, including that the introduction of each team member and his or her role had occurred. Each member of the OR team was individually approached by one volunteer after each general surgical case was completed in the 25 ORs involved. No individual was questioned more than once. Because of the regular interaction of team members in subspecialty services (obstetrics, neurosurgery, and cardiology), these cases were excluded. OR Team Members’ Completion of the Form
The OR team members (that is, the anesthesiology attending [AA], anesthesiology resident [AR], circulating nurse [CN], scrub nurse [SN], surgery attending [SA], and surgery resident [SR]) were asked independently to complete a form on exiting the OR that asked them to name each of the members of the team (either first or last name) with whom they had just worked. In addition, they were asked to respond to the following two-item attitudinal questionnaire using a 5-point Likert scale (1 = Not important at all; 5 = Extremely important): (1) “How important is it that everyone in the OR knows your name?”; (2) “How important is it to you that you know everyone’s name in the OR?” Each person was approached simultaneously by a different volunteer, except the anesthesia provider(s), who was interviewed in the postanesthesia care unit after sign-out of the patient. If any member of the team had been previously interviewed, his or her entire team was excluded from the study. Statistical Analyses
A generalized linear mixed model was used to analyze the number of individuals in the OR whom the participant rater knew or who knew the participant rater. Fixed effects were participant rater (AA, AR, SA, SR, CN, and SN), type (that is, profession), and their interaction. The correlated data structure was represented by a heterogeneous compound symmetric covariance matrix. Planned comparisons were made between types for each participant rater and among participant raters within each type.
Name Recognition in the Operating Room
Attitudinal data related to the importance of knowing names (for example, how important is it for me to know them, or how important is it for them to know me) were analyzed with a general linear mixed model for a repeated measures analysis of variance. Fixed effects were participant rater (AA, AR, SA, SR, CN, and SN), type (self and other), and the interaction or participant rater and type. The random effect was participant rater nested within odds ratio. The correlated data structure was represented by an unstructured covariance matrix. Planned comparisons were made between types for each participant rater and among participant raters within each type. Pearson correlation analysis was used to test the strength of association between the importance of knowing my name and the number of others who knew my name, and the importance of knowing others’ names and the number of others whose names were known. A simple cross-tabulation between pairs of participant raters was used to produce frequency and percentage of specific OR personnel whose name was known to each participant rater. The two-tailed 0.05 alpha level was used to establish statistical significance. SAS 9.3 (SAS Institute Inc.; Cary, North Carolina) was used for all statistical analyses. RESULTS
A total of 150 OR personnel were interviewed at the completion of 25 cases, with each selected OR having five team members. Of these respondents, 147 (98%) members of the OR staff could name the SA (mean 4.9/5, p < 0.001); however, the SA could name only 44% of the OR staff (mean 2.2, p < 0.001). Sixty-two percent of the OR staff could name the AA (mean 3.1), and the AA named others 64% of the time (mean 3.2). The AR was able to name 82% of the OR team (mean 4.1, p < 0.001) yet was named by others only 28% of the time (mean 1.4). The CN could name 80% of the OR team (mean 4.0, p < 0.003) and was named by 50% of the OR team (mean 2.5). The SR was able to name 50% of the team (mean 2.5, p = 0.060) and was named by 68% (mean 3.4) (Table 1). The AA and AR were able to name one another 100% of the time; however, the SA could name the SR only 68% of the time (p = 0.002). The AR could name the SA 96% of the time, whereas the SA named the AR 0% of the time (p < 0.001). The AR could name the SR 76% of the time, but the SR could correctly name the AR only 28% of the time (p < 0.001) (Table 2). Regarding attitudes related to the importance of knowing names and being known by the OR team, the anesthesia staff believed that it is significantly more important for them to know others (4.4; 4.5) than for others to know them (4.0; 3.8). Conversely, the surgical staff expressed the belief that it is significantly more important for others to know them (4.7; 3.9) than for them to know others (2.5; 3.1). The nursing staff give equal importance for knowing others and being known (CN 4.5; 4.4; SN 3.8;3.6) (Table 3).
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Table 1. Time-Outs Matter: An Evaluation of Introductions in the Operating Room* Number of ORP Who
Others Knew Me
I Knew Others
Diff
Others Knew Me
Mean
SE
Mean
SE
P
AA
AR
3.1 1.4 2.5 4.9 3.6 3.4
0.4 0.2 0.3 0.4 0.4 0.4
3.2 4.1 4.0 2.2 2.9 2.5
0.4 0.4 0.4 0.3 0.3 0.3
0.874 < 0.001 0.003 < 0.001 0.211 0.060
< 0.001 0.179 0.002 0.396 0.584
< 0.010 < 0.001 < 0.001 < 0.001
AA AR CN SA SN SR
CN
< 0.001 0.030 0.060
I Knew Others SA
0.025 0.011
SN
AA
AR
CN
SA
SN
0.762
0.105 0.138 0.033 0.572 0.133
0.888 < 0.001 0.030 0.002
< 0.001 0.042 0.003
0.114 0.518
0.345
*Number of operating room (OR) team members whom each member can name and the number of team members who named him or her—by OR personnel (“the average number of OTHERS whom I know and the average number of others who know ME”). ORP, operating room personnel/team members; SE, standard error; AA, anesthesiology attending; AR, anesthesiology resident; CN, circulating nurse; SA, surgery attending; SN, scrub nurse; SR, surgery resident.
Table 2. Recognition Among the Surgery and Anesthesiology Attendings and the Residents Rater knew Rater
AA (n = 25)
AA No. (%) AR No. (%) SA No. (%) SR No. (%)
AR (n = 25)
SA (n = 25) 23 (92)
25 (100)*
SR (n = 25)
†
7 (28)
24 (96)‡
25 (100) 14 (56)
0 (0)
6 (24)
7 (28)
19 (76)§ 17 (68)||
25 (100)
*p = 0.002. † p = 0.004. ‡ p < 0.001. § p < 0.001. || p = 0.002. AA, anesthesiology attending; AR, anesthesiology resident; SA, surgery attending; SR, surgery resident.
DISCUSSION
The use of checklists has been shown in HROs to improve reliability and reduce risk from human error,5 yet their effectiveness in the health care domain remains unproven.
Documented compliance using SSCs does not measure implementation fidelity because not all items on the checklist may be performed as intended.19 However, it has been suggested that up to 50% of adverse events are likely avoidable and that checklists may be a key component to diminishing such failures.20 This is particularly important in the OR, where the team is committed to a common purpose, performance goals, and mutual accountability.21,22 Although not explicitly stated, it is commonly understood that the WHO SSC recommendation for team members to state name and role is specifically intended to promote mutual trust and team orientation, essential for highly reliable team function. In theory, the WHO SSC requirement should promote better teamwork and, consequently, surgical patient safety. The fact that the majority of OR team members in this study did not know their colleagues’ names after having made such introductions at the beginning of the case suggests that promoting teamwork and HRO–like function is more nuanced than simply instituting checklist procedures and protocols. In fact, mindfulness in lieu of mindlessness is a defining feature of HROs.23 If a time-out becomes perfunctory, it may undermine the required focus needed for effectiveness.24
Table 3. The Importance of Others in the OR Knowing My Name and the Importance of My Knowing the Names of Others in the OR—by OR Personnel* Importance
Others Know Me
Who
Mean
SE
Mean
4.0 3.8 4.5 4.7 3.8 3.9
0.1 0.1 0.1 0.1 0.1 0.1
4.4 4.5 4.4 2.5 3.6 3.1
AA AR CN SA SN SR
I Know Others SE
Diff P
Others Knew Me AA
AR
CN
SA
I Knew Others SN
AA
AR
CN
SA
SN
0.2 0.028 0.2 < 0.001 0.372 0.720 0.2 0.405 0.008 0.001 0.858 0.858 0.2 < 0.001 0.001 < 0.001 0.503 < 0.001 < 0.001 < 0.001 0.2 0.405 0.265 0.823 < 0.001 < 0.001 0.005 0.002 0.003 < 0.001 0.2 < 0.001 0.655 0.655 0.002 < 0.001 0.503 < 0.001 < 0.001 < 0.001 0.021 0.051
*Using a 5-point Likert scale (1 = “Not important at all”; 5 = “Extremely important”), participants were asked “How important is it that everyone in the OR knows your name?” and “How important is it to you that you know everyone’s name in the OR?” OR, operating room; SE, standard error; AA, anesthesiology attending; AR, anesthesiology resident; CN, circulating nurse; SA, surgery attending; SN, scrub nurse; SR, surgery resident.
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The findings of this study suggest that mandatory introductions alone will not resolve all of the OR communication challenges. Advanced training, including high-fidelity simulation, should be considered to improve this type of communication. The individual most often identified by the OR team was, not surprisingly, the attending surgeon. This individual was also the person who felt it was the most important for others to know his or her name. Of note, many surgeons in our study did not believe that knowing other team members’ names was important. Such attitudes may reflect a hierarchal power structure in which the surgeon views himself or herself as the captain of the ship through whom everything must proceed. However, they may also reflect an underappreciation of the importance of knowing names for team leadership (that is, being able to delegate roles, coordinate care, or create mutual trust and team orientation). Another reason for the recognition of the surgeon by other team members may be his or her constancy as a team member. OR staff turnover during a case can be frequent for breaks and shift changes. Attending surgeons typically do not switch out in this manner, making them the one constant. A disconnect illustrated by this study is that attending anesthesiologists, in contradistinction to attending surgeons, believe it is significantly more important for them to know others than for others to know them. Such an attitude is potentially reflected in the finding that the AA or the AR was the least readily identified individual in the OR. Of particular concern regarding teamwork and an optimal learning environment, the SA was sometimes unable to name the SR with whom he or she was working. This may be related to the finding that the surgeons believed it is significantly more important for others to know them than for them to know others. Identifying that the attitude of the SRs was similar to their attendings might suggest that mentors affect the trainees’ belief system about communication and teamwork in the OR.25 The findings of this study have implications for nurses, as well as physicians. The CN is an essential member of the OR team, and, during an intraoperative crisis, is critical in coordinating care and delivering therapy. That said, in this study the CN could be named by only 50% of the team. The surgical SNs, on the other hand, similar to their surgical colleagues, believed that it is less important to know others but important for others to know them. These findings that attitudes toward knowing names and having names known were similar among the anesthesia staff and CNs versus among surgical staff and SNs may also be a reflection of the silo mentality within the OR.26 Clearly, the surgical team (surgeons and SN) is ensconced within a silo in which they accept attention and support from the other members of the team. In contrast, the anesthesia staff and CN may be more inclined to see themselves as helping with the case and not needing to be known. Limitations
This study has several limitations. First, it was conducted at several hospitals of a large academic medical center. Results
Name Recognition in the Operating Room
may differ considerably from those at smaller or nonacademic institutions, where there is less variability of staff and where interactions occur more frequently. Second, we were unable to randomize the groups (SSC vs. no SSC) because the use of the SSC was standard procedure at the participating hospitals. Third, because the CNs documented the names of the team in the electronic medical record, they may have a higher name recall than the others. Fourth, the study did not demonstrate that knowing an OR colleague’s name leads to an improved outcome, or conversely, that lack of recall of names leads to worse outcomes. There is also the challenge of remembering names throughout the case, and studies suggest that name retention is poor.27 Finally, in an academic setting, surgeons may often be working in two ORs. Nonetheless, anesthesia personnel, who also cover more than one OR at a time, were found to have far better name recall. CONCLUSION
Relying on checklists alone will not lead to sustained reduction in surgical errors. Although the literature shows that effective communication of the surgical team leads to lower mortality rates, failures in communication have also been associated with high nursing staff turnover,28 which represents a continuing crisis in health care.29 Moreover, our findings suggest that introductions at the start of the timeout are often suboptimal, particularly in busy academic centers where there is great variability of staffing. If the attending physician is not present during the time-out, or if the team does not take this activity seriously and participate,30 introductions are rendered meaningless. Further, checklist use, in and of itself, is not a magic bullet.31 It is not simply ticking off items on a checklist that reduces complications but a strong belief in the importance of the acts the checklist demands.32 Conflicts of Interest. All authors report no conflicts of interest.
David J. Birnbach, MD, MPH, is Miller Professor of Anesthesiology and Public Health Sciences, and Director, University of Miami-Jackson Memorial Hospital Center for Patient Safety, University of Miami Miller School of Medicine. Lisa F. Rosen, MA, is Senior Researcher, and Maureen Fitzpatrick, MSN, ARNP-BC, is Research and Education Specialist, University of Miami-Jackson Memorial Hospital Center for Patient Safety. John T. Paige, MD, is Associate Professor of Clinical Surgery, and Director of Wound Care, Department of Surgery, LSU Health Sciences Center, New Orleans. Kristopher L. Arheart, EdD, is Associate Professor, Division of Biostatistics, Department of Public Health Sciences, University of Miami Miller School of Medicine. Please address correspondence to David J. Birnbach,
[email protected].
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