Search

Purpose: To determine the type and frequency of errors during vascular interventional radiology (VIR) and design and implement an intervention to reduce error and improve efficiency in this setting., Materials and Methods: Ethical guidance was sought from the Research Services Department at Imperial College London. Informed consent was not obtained. Field notes were recorded during 55 VIR procedures by a single observer. Two blinded assessors identified failures from field notes and categorized them into one or more errors by using a 22-part classification system. The potential to cause harm, disruption to procedural flow, and preventability of each failure was determined. A preprocedural team rehearsal (PPTR) was then designed and implemented to target frequent preventable potential failures. Thirty-three procedures were observed subsequently to determine the efficacy of the PPTR. Nonparametric statistical analysis was used to determine the effect of intervention on potential failure rates, potential to cause harm and procedural flow disruption scores (Mann-Whitney U test), and number of preventable failures (Fisher exact test)., Results: Before intervention, 1197 potential failures were recorded, of which 54.6% were preventable. A total of 2040 errors were deemed to have occurred to produce these failures. Planning error (19.7%), staff absence (16.2%), equipment unavailability (12.2%), communication error (11.2%), and lack of safety consciousness (6.1%) were the most frequent errors, accounting for 65.4% of the total. After intervention, 352 potential failures were recorded. Classification resulted in 477 errors. Preventable failures decreased from 54.6% to 27.3% (P < .001) with implementation of PPTR. Potential failure rates per hour decreased from 18.8 to 9.2 (P < .001), with no increase in potential to cause harm or procedural flow disruption per failure., Conclusion: Failures during VIR procedures are largely because of ineffective planning, communication error, and equipment difficulties, rather than a result of technical or patient-related issues. Many of these potential failures are preventable. A PPTR is an effective means of targeting frequent preventable failures, reducing procedural delays and improving patient safety.

Objective: To evaluate information transfer and communication (ITC) across the surgical care pathway with the use of Information Transfer and Communication Assessment Tool for Surgery (ITCAS)., Background: Communication failures are the leading cause of surgical errors and adverse events. It is vital to assess the ITC across the entire surgical continuum of care to understand the process, to study teams, and to prioritize the phases for intervention., Methods: Twenty patients undergoing major gastrointestinal procedures were followed through their entire surgical care, and ITC process was assessed using ITCAS. ITCAS consisted of 4 checklists for 4 phases of the surgical care., Results: ITC failures are distributed across the entire surgical continuum of care. Preprocedural teamwork and postoperative handover phases have the maximum number of ITC failures (61.7% and 52.4%, respectively). Moreover, it was found that information degrades as it crosses from one phase to another. Of patients, 75% had clinical incidents or adverse events because of ITC failures., Conclusions: The study demonstrated that ITC failures are ubiquitous across surgical care pathway and there is an imminent need to modify current ITC practices. Standardization of ITC through use of checklists, protocols, or information technology is essential to reduce these communication failures.

Objectives: We conducted a systematic review of published literature to gain a better understanding of interprofessional information transfer and communication (ITC) in hospital setting in the field of surgical and anesthetic care., Background: Communication breakdowns are a common cause of surgical errors and adverse events., Data Sources: Medline, Embase, PsycINFO, Cochrane Database of Systematic Reviews, and hand search of articles bibliography., Study Selection: Of the 4027 citations identified through the initial electronic search and screened for possible inclusion, 110 articles were retained following title and abstract reviews. Of these, 38 were accepted for this review., Data Extraction: Data were extracted from the studies about objectives, clinical domain, methodology including study design, sample population, tools for assessing communication, results, and limitations., Results: Information transfer failures are common in surgical care and are distributed across the continuum of care. They not only lead to errors in care provision but also lead to patient harm. Most of the articles have focused on ITC process in different phases especially in operating room. None of the studies have looked at whole of the surgical care process. No standard tool has been developed to capture the ITC process in different teams and to evaluate the effect of various communication interventions. Uses of standardized communication through checklist, proformas, and technology innovations have improved the ITC process, with an effect on clinical and patient outcomes., Conclusions: ITC deficits adversely affect patient care. There is a need for standard measures to evaluate this process. Effective and standardized communication among healthcare professionals during the perioperative process facilitates surgical safety.

Hypothesis: Health care failure mode and effect analysis identifies critical processes prone to information transfer and communication failures and suggests interventions to improve these failures., Design: Failure mode and effect analysis., Setting: Academic research., Participants: A multidisciplinary team consisting of surgeons, anesthetists, nurses, and a psychologist involved in various phases of surgical care was assembled., Main Outcome Measures: A flowchart of the whole process was developed. Potential failure modes were identified and evaluated using a hazard matrix score. Recommendations were determined for certain critical failure modes using a decision tree., Results: The process of surgical care was divided into the following 4 main phases: preoperative assessment and optimization, preprocedural teamwork, postoperative handover, and daily ward care. Most failure modes were identified in the preoperative assessment and optimization phase. Forty-one of 132 failures were classified as critical, 26 of which were sufficiently covered by current protocols. Recommendations were made for the remaining 15 failure modes., Conclusions: Modified health care failure mode and effect analysis proved to be a practical approach and has been well received by clinicians. Systematic analysis by a multidisciplinary team is a useful method for detecting failure modes.

The advancement of surgical technology has made surgery an increasingly suitable management option for an increasing number of medical conditions. Yet there is also a growing concern about the number of patients coming to harm as a result of surgery. Studies show that this harm can be prevented by better teamwork and communication in operating theatres. This article discusses the extent of adverse events in surgery and how effective teamwork and communication can improve patient safety. It also highlights the role checklists and briefing in improving teamwork and reducing human error in surgery.