Interventions: What is currently being done to prevent these adverse events?
In response to the high rate of AE incidence, patient safety initiatives have focused on developing error prevention interventions in a surgical setting. Such interventions include the Surgical Safety Checklist, post-operative debriefing, and surgical education programs.
Checklists
Adopted from the aviation industry, the Surgical Safety Checklist was developed to improve adherence to clinical protocols by promoting teamwork, communication, and safety culture.Implementation of the checklist has shown to decrease mortality rates from 1.5% to 0.8% and complication rates from 11% to 7%; however, effectiveness of intervention varied significantly across hospitals124. A recent Ontario study used administrative data to survey acute care hospitals and found that implementation of checklists did not result in improved patient outcome125. In a controlled intervention study, the checklist was shown to have limited impact on perceptions of safety culture as compared to the control group126. The issue with the checklist is that it may be reduced to a subconscious “tick box” exercise127. Further studies involving strategies to improve checklist effectiveness are warranted128.
Performance Feedback
Performance feedback allows individuals to reflect on their personal and team performance, and work towards developing strategies to improve future performance129,130. In a surgical setting, performance feedback has been shown to improve technical performance131-134, reduce the incidence of AEs132, and decrease procedure times134. Despite these documented benefits, current literature suggests a lack of debriefing culture in the OR135. Few studies have developed approaches to improving debriefing in surgery136,137. While some tools provide guidelines for debriefing, such as the Objective Structured Assessment of Debriefing (OSAD)138, performance feedback is often subjective with little structure.139.
Surgical Education Programs
Traditional training programs are based on the principle of “see one, do one, teach one”140. This apprenticeship model is not ideal as it assumes competency of the trainee after performing a specific number of procedures or completing a predetermined number of postgraduate years141. In fact, this model has no standardized method of evaluating “competency” of a surgeon, and takes senior opinion as the “gold standard” of surgical skill. Recent training programs have drifted away from the time-based training model, and have started to adopt competence-based education – a training paradigm that involves learning, repeated practice, performance and evaluation. Competence-based surgical training programs are developed through expert opinion (i.e., Delphi Methodology) and textbook evidence, and incorporate a variety of training components such as didactic learning, simulation-based crisis scenarios, and technical skills training using box trainers and VR simulators142.
While current training interventions have shown to improve patient safety in the OR, these solutions are missing out on a key concept: what are the underlying mechanisms of AEs and how do we reduce their occurrence? Adverse events are caused by a multitude of underlying factors, though some factors are more hazardous to patient safety than others. These high-impact factors should be targeted in training interventions to maximize its effect on surgical performance. In order to gain a full understanding of what causes an AE, the OR must be looked at from multiple aspects to analyze the organizational, situational, team, individual, task and patient factors that influence patient outcome.