[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 54.147.238.168. Please contact the publisher to request reinstatement.
Sign In
Individual Sign In
Create an Account
Institutional Sign In
OpenAthens Shibboleth
[Skip to Content Landing]
Download PDF
Figure.
Percentage of First Case On-Time Starts by Month Since Implementation of the Automated Workflow System
Percentage of First Case On-Time Starts by Month Since Implementation of the Automated Workflow System
Table.  
Responses to Survey by OR Physicians and Registered Nurses
Responses to Survey by OR Physicians and Registered Nurses
1.
Gawande  A. The Checklist Manifesto: How to Get Things Right. New York, NY: Metropolitan Books/Henry Holt and Co; 2011.
2.
World Alliance for Patient Safety; World Health Organization. Safe surgery saves lives: second global patient safety challenge. http://www.who.int/patientsafety/safesurgery/knowledge_base/SSSL_Brochure_finalJun08.pdf. Accessed March 24, 2014.
3.
World Health Organization. Surgical safety checklist (first edition). http://www.who.int/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJun08.pdf. Accessed March 24, 2014.
4.
Haynes  AB, Weiser  TG, Berry  WR,  et al; Safe Surgery Saves Lives Study Group.  A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-499.
PubMedArticle
5.
Russ  S, Rout  S, Sevdalis  N, Moorthy  K, Darzi  A, Vincent  C.  Do safety checklists improve teamwork and communication in the operating room? a systematic review. Ann Surg. 2013;258(6):856-871.
PubMedArticle
6.
Urbach  DR, Govindarajan  A, Saskin  R, Wilton  AS, Baxter  NN.  Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med. 2014;370(11):1029-1038.
PubMedArticle
Views 1,210
Citations 0
Research Letter
Association of VA Surgeons, Innovation in Safety: Safety in Innovation
November 2014

The Automated Operating RoomA Team Approach to Patient Safety and Communication

Author Affiliations
  • 1Bruce W. Carter Department of VA Medical Center, Miami VA Healthcare System, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida
JAMA Surg. 2014;149(11):1209-1210. doi:10.1001/jamasurg.2014.1825

For decades, high-risk industries have relied on safety checklists to limit the adverse consequences of human error.1 The checklist model has only recently been adapted in the surgical field after the World Health Organization launched the “Safe Surgery Saves Lives” campaign in 2006.2,3 Various studies4,5 have shown that the use of checklists reduces death rates and perioperative complication rates, and their use also improves teamwork and communication, potentially contributing to improved patient outcomes. On the other hand, a recent study6 from Canada showed that this tool did not reduce mortality rates or the numbers of complications, emergency department visits, and readmissions. While the use of a checklist remains a standard of care, the priority has shifted to patient safety, compliance with mandates, efficiency, and the monitoring of outcomes. These parameters are much harder to quantify.

The Veterans Health Administration’s initiative to improve operating room safety and efficiency has motivated the Bruce W. Carter Department of Veterans Affairs (VA) Medical Center of the Miami VA Healthcare System to investigate a technology-enabled solution to automate safety checklists, integrate patient data, and track staff compliance with safety measures. Before the automated system, the Miami VA Healthcare System was only capable of auditing 5% of cases for checklist compliance, which is insufficient to ensure proper utilization, standardization, and accountability.

Methods

In June 2013, an automated workflow system (AWS; OR-Dashboard [LiveData]) was implemented at the Miami VA Healthcare System to provide a common display of perioperative data elements, viewable to every member of the surgical team. The goal was to enhance surgical team communication during the checklist process and throughout each case. Monthly reports were generated to analyze nationally reported metrics and to assess staff compliance with the checklists. Eight months after implementation, 46 surgical team members, including physicians, residents, nurses, certified registered nurse anesthetists, and surgical technicians, completed a survey about their experience with the AWS pertaining to patient safety, “timeout” efficiency, compliance, and team communication. Anonymous responses were collected using a 5-point Likert scale.

Results

One month after the implementation of the AWS, checklist compliance reached 89% for “preprocedure,” 95% for timeout, and 82% for “debrief.” The remainder of compliance was achieved using the conventional method for a total of 100%. Six months after implementation, compliance with the AWS timeout was 99%.

During the first 6 months of the AWS, first case on-time starts improved from 47% to 85%. The median timeout duration improved from 71 to 58 seconds over this same time period (Figure). Survey results show that 93% of nurses “strongly agree” or “agree” that the AWS enhances surgical team engagement, improves patient safety, and provides opportunities to prevent errors; 86% of nurses strongly agree or agree that the AWS improves the operative team’s communication compared with traditional checklist methods; more than 74% of physicians strongly agree or agree that the AWS improves surgical team engagement, improves patient safety, and improves compliance with Surgical Care Improvement Project documentation; and 100% of nurses and 79% of physicians strongly agree or agree that the AWS is user friendly (Table).

Discussion

The AWS provides a consistent, reliable, and user-friendly method for completing the surgical safety checklist and for improving operative team engagement in the process. Since implementation of the AWS at our facility, first case on-time starts have improved by 40%, and automated safety checklist compliance with timeout has improved by 4%. Cases with less than 100% compliance were reviewed, and deficiencies were attributed to, among other things, the staff learning curve and technical problems with implementation early in use. Surveys show that physicians and staff members believe that the AWS improves communication, team engagement, patient safety, and compliance with Surgical Care Improvement Project measures. Future goals for the AWS at our facility include tracking near misses to improve patient safety and staff education opportunities, developing a structured feedback system for operative team members, and incorporating other risk assessments.

Back to top
Article Information

Corresponding Author: Juliet Nissan, MD, Bruce W. Carter Department of VA Medical Center, Miami VA Healthcare System, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1611 NW 12th Ave, East Tower, Ste 2169, Miami, FL 33136 (jjnissan@med.miami.edu).

Published Online: September 24, 2014. doi:10.1001/jamasurg.2014.1825.

Author Contributions: Dr Nissan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Nissan, Campos, Spector.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Nissan, Campos, Delgado, Spector.

Administrative, technical, or material support: Matadial, Spector.

Study supervision: Matadial, Spector.

Conflict of Interest Disclosures: None reported.

Previous Presentation: The paper was presented at the 38th Annual Surgical Symposium of the Association of VA Surgeons; April 7, 2014; New Haven, Connecticut.

Additional Information: LiveData, the company that manufactured the AWS used at our institution (OR-Dashboard), had no role in the design and conduct of the study; analysis and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Gawande  A. The Checklist Manifesto: How to Get Things Right. New York, NY: Metropolitan Books/Henry Holt and Co; 2011.
2.
World Alliance for Patient Safety; World Health Organization. Safe surgery saves lives: second global patient safety challenge. http://www.who.int/patientsafety/safesurgery/knowledge_base/SSSL_Brochure_finalJun08.pdf. Accessed March 24, 2014.
3.
World Health Organization. Surgical safety checklist (first edition). http://www.who.int/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJun08.pdf. Accessed March 24, 2014.
4.
Haynes  AB, Weiser  TG, Berry  WR,  et al; Safe Surgery Saves Lives Study Group.  A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-499.
PubMedArticle
5.
Russ  S, Rout  S, Sevdalis  N, Moorthy  K, Darzi  A, Vincent  C.  Do safety checklists improve teamwork and communication in the operating room? a systematic review. Ann Surg. 2013;258(6):856-871.
PubMedArticle
6.
Urbach  DR, Govindarajan  A, Saskin  R, Wilton  AS, Baxter  NN.  Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med. 2014;370(11):1029-1038.
PubMedArticle
×