Two-minute briefing may reduce wrong-site surgeries
Effective communication critical to improvement
Researchers at Johns Hopkins Hospital and the Johns Hopkins School of Medicine in Baltimore have determined that a simple two-minute briefing prior to surgery may have a significant impact on reducing wrong-site surgeries. Their work is described in a recent issue of the Journal of the American College of Surgeons.1
A group of 147 Johns Hopkins surgeons, anesthesiologists, and nurses was surveyed prior to and following the implementation of this new policy. After they were trained in the briefing, there was a 13.2% increase in those who thought the policy would be effective, and more than 90% thought it was important to patient safety.
The study also showed specific improvements in communications, based on six items in the survey. For example, to the item, "Surgery and anesthesia worked together as a well-coordinated team," 67.9% agreed pre-briefing, while 91.5% agreed post-briefing. And for the statement, "A preoperative discussion increased my awareness of the surgical site and side being operated on," 52.4% agreed pre-briefing, while 64.4% agreed post-briefing.
"We know that in any high-risk industry that standardizing what you do improves performance, and we found those same rules apply to communication," asserts Peter J. Pronovost, MD, PhD, associate professor, departments of anesthesiology and critical care medicine and surgery, Johns Hopkins School of Medicine and department of health policy & management, Bloomberg School of Public Heath; medical director, Center for Innovations in Quality Patient Care; director, Division of Adult Critical Care; and a co-author of the article. "And, we know poor communications are the No. 1 cause of sentinel events. These briefings are a standardized way to cover all the necessary preoperative safety elements, and an opportunity for the entire care team to surface any hazards."
Pronovost goes on to note that they "have identified in most sentinel events that somebody knew something was wrong and did not speak up, or was not listened to. We do that all the time in health care; we do not listen to the nurses, techs, and so forth. The briefing gives you an additional number of eyes looking at the patient."
How the briefing works
The briefing, Pronovost explains, involves the entire care team — the surgeon, anesthesiologist, nurses, and, at Hopkins (and other academic centers), the residents. "It often happens with the patient already in the OR; they were also often asleep, as was the case in our hospital," he notes.
The briefing begins with everyone introducing themselves with their names (first name included) and their role (i.e., "I am Dr. John Smith, and I am the anesthesiologist."). "You want to break down the barriers to communication," Pronovost observes.
The second part of the briefing involves the "time out" recommended by The Joint Commission. "This involves stating what we are about to do, who the patient is, confirming we have the necessary consents, and all team members agreeing the consent matches what we are about to do," says Pronovost.
In the third part of the briefing, "We try to surface any hazards by asking if anyone has any concerns," notes Pronovost. "In addition we ask, 'If something would go wrong, what would it be, and how would we defend it?'"
Next, the team is asked if they have all the equipment they are going to need and whether they have people who know how to use that equipment. "When you look at sentinel events, equipment keeps occupying a higher and higher percentage as a cause," Pronovost observes. Finally, the team is explicitly asked about its efforts to reduce infections — i.e., did they get the necessary antibiotics?
Believe it or not, these briefings take all of two minutes. "There's a tension we see when you put too much detail in; it becomes a meeting," says Pronovost. "We found addressing a smaller number of key items makes you much more successful."
Apply principles broadly
While advocating these briefings for all facilities, Pronovost is not suggesting you follow the Hopkins model — in fact, he says, it's preferable if you design your own briefings.
"I think these principles should be broadly applied," he clarifies. "What I'm suggesting is, what we have to take away from this study are the concepts and principles. What we probably shouldn't do is broadly adopt the Hopkins method."
In other words, he continues, you should adopt the concept of standardizing your briefing, but adapt it to your culture. "You should develop the exact questions on your own; if you do not develop it locally, it will not work."
Pronovost saw a clear example in his own facility. "When we started, we tried to make a standard form for all our ORs," he recalls. "One of the questions was, 'Did the patient get beta-blockers?' One pediatric surgeon said to me, 'Why am I asking this question?'"
Your orthopedic service, he notes, may have very different needs than your cardiac service. "Orthopedics may, for example, wish to ask if artificial limbs have been sterilized in a particular way," he offers.
Still, says Pronovost, all briefings should have some basic elements. "You have to have the opportunity to identify yourself, you have to have the timeout components, and you need a way to identify and mitigate hazards," he advises. "The details could often vary, but the mean concepts are pretty much the same."
Reference
- Makary MA, Mukherjee A, Sexton JB, Syin D, Goodrich E, Hartmann E, Rowen L, Behrens DC, Marohn M, Pronovost PJ. Operating room briefings and wrong-site surgery. J Am Coll Surg 2007 February; 204(2):236-243.
For more information, contact:
Peter J. Pronovost, MD, PhD, Associate Professor, Departments of Anesthesiology and Critical Care Medicine and Surgery, Johns Hopkins School of Medicine, Baltimore, MD. Phone: (410) 502-3231. E-mail: [email protected].
Researchers at Johns Hopkins Hospital and the Johns Hopkins School of Medicine in Baltimore have determined that a simple two-minute briefing prior to surgery may have a significant impact on reducing wrong-site surgeries. Their work is described in a recent issue of the Journal of the American College of Surgeons.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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