Martinez, EA SCA CPB 2012 Improving Quality and Patient Safety: Focusing on Checklists, Time-­outs, Huddles, and Sign-­offs Elizabeth A. Martinez, MD, MHS Department of Anesthesia, Critical Care and Pain Medicine Massachusetts General Hospital Harvard Medical School Boston, MA 1. Describe the need for better communication in and out of the operating room
2. Review how the use of checklists in the operating room improves communication
3. Appreciate the impact on patient safety when communication goes awry
Introduction:
Teamwork and communication breakdown are frequently at the heart of medical errors
in the surgical domain.1, 2 There are multiple ways to assess and improve teamwork
and communication. During this session we will discuss tools that can be used in the
perioperative setting to improve communication, teamwork, and patient safety.
Checklists:
Since the 1950s there have been incredible advances in medical knowledge, therapies
and treatments, and technology. This all adds up to increased complexity and an
increased cognitive workload for healthcare providers. While our knowledge has
advanced, we continue to make mistakes, missing the ‘simple’ stuff due to the
overwhelming demands of this cognitive workload. Many of the mistakes – or avoidable
harms – are because we do not apply our knowledge consistently and correctly.
In the healthcare, like other complex systems, we are faced with two challenges: 3
1) Fallibility of human memory and attention, especially when it comes to mundane
or routine matters.
2) People inadvertently skip steps for a wide variety of reasons, even when they
remember them.
The use of checklists has been a mainstay of practice in safety-conscious and high
reliability industries such as aviation and nuclear power, and are frequently used to
1 Martinez, EA SCA CPB 2012 address the challenges described above. The use of checklists and reminders is
nothing new in healthcare – we have been using them for years to help us learn our
differential diagnoses, performing safety checks on our equipment, and other
individualized tasks. Checklists are now being introduced in ICUs, operating rooms, and
other health care applications to increase standardization and create redundancies in
our workflow, thereby improving quality and safety.
In a 2006 NEJM article, Pronovost, et al., describe their use of a checklist to reduce the
rates of catheter-associated blood stream infections (CA-BSIs) in a group of Michigan
ICUs.4 This checklist incorporated five evidence-based practices that had been shown
to reduce CA-BSIs. In addition, in 2009, Gawande and colleagues presented their work
to quantify the impact of surgical safety checklists on outcomes. Both of these studies
incorporated evidence-based practices into the checklists. In addition to serving as a
reminder to deliver best practices (task list),4 checklists can also serve as
communication tools.3, 5 While both of these examples above can guide the
conversation about important evidence-based practices, the surgical safety checklist is
particularly advantageous in that it encourages all team members to share their
concerns about the specific patient. This leveling of the OR hierarchy enables more
pairs of eyes to be trained on the process and provide more opportunities to alert the
rest of the team should the need arise. We all know that improving patient safety
requires a 360-degree view: team members must be able to speak up.
Briefings:
A briefing is an opportunity for a team to develop a shared mental model of the activities
around a certain event. It involves bringing team members together, ideally in a face-toface fashion to gain a shared understanding of what the current state is (what is going
on now) and what the expectations for next events are. The briefing improves a teams’
collective situational awareness: the ability to identify, process and predict the critical
elements of information about the team’s mission and its current status. Effective
situational awareness draws on a common knowledge base and helps team members
coordinate actions in a unified response.
The healthcare briefing is a guided, succinct discussion of a healthcare event or period.
It should occur at least prior to procedures and during shift changes. The goal is to map
out a plan of care and clarify roles and responsibilities. The team leader is responsible
for ensuring all team members share concerns and raise unexpected issues which may
have transpired during the event. The team leader can use a checklist to guide the initial
discussion, and should elicit a culture of open conversation about issues or concerns,
for instance asking “what potential problems do you foresee?” Other examples of
briefings include the time-out prior to incision, daily goals sheets in the ICU6 and handoff
checklists between7 and within clinical teams. These perioperative briefings will be
discussed during the session.
2 Martinez, EA SCA CPB 2012 References:
1. 2. 3. 4. 5. 6. 7. Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. Jun 2003;133(6):614-­‐621. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. Oct 2004;13(5):330-­‐334. Gawande A. The checklist manifesto : how to get things right. 1st ed. New York: Metropolitan Books; 2010. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-­‐
related bloodstream infections in the ICU. N Engl J Med. Dec 28 2006;355(26):2725-­‐
2732. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. Jan 29 2009;360(5):491-­‐499. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. Jun 2003;18(2):71-­‐75. Petrovic MA, Aboumatar H, Baumgartner WA, et al. Pilot Implementation of a Perioperative Protocol to Guide Operating Room-­‐to-­‐Intensive Care Unit Patient Handoffs. J Cardiothorac Vasc Anesth. Sep 1. 3