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Implementing Crew Resources
https://t.me/med1917
Management Principles toImprove
15
Perioperative Safety
AbdulelahAlhawsawi andM.SofiaMacedo
It is estimated that more than 230million surgeries are performed globally every
year [1]. According to the World Health Organization (WHO), the signicant complications rate could reach up to 16% of all surgical procedures, with mortality rates
ranging between 0.4% and 0.8% [2]. However, a recent study has found the rates of
surgical complications to be much higher [3]. This was a prospective study of more
than 46,000 surgical patients across 498 European hospitals that found a mortality
rate as high as 4% for all non-cardiac, obstetric, or neurosurgical inpatient surgical
admissions. With almost 7million people worldwide harmed annually due to perioperative surgical complications, and a mortality rate of up to 10% in developing
countries, it has become evident that improving perioperative patient safety is an
essential requirement for all healthcare systems globally [2].
Safe Operating Room
The operating room (OR) is one of the most essential and dynamic units within the
hospital. The level of complexity, speed, and culture has a direct impact on patient
safety. In its efforts to improve safety in this high-stakes and potentially high-risk
unit, the Saudi Patient Safety Center (SPSC) issued a publication as a guideline to
hospitals for establishing safe operating rooms (SOR).
The following components are needed to establish an SOR while keeping the
focus on the patient:
A. Alhawsawi (*)
Novo Genomics, Riyadh, Saudi Arabia
e-mail: a.alhawsawi@novo-genomics.com
M. S. Macedo
Center for National Health Insurance, Ar Rabi, Riyadh, Saudi Arabia
© Springer Nature Switzerland AG 2024
J. J. Hoballah et al. (eds.), Principles of Perioperative Safety and Efciency,
https://doi.org/10.1007/978-3-031-41089-5_15
251
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1. Competent Leadership. Operating room director and specialized nursing man-
ager with experience and focus on safety (patients, staff).
2. Competent operating room staff. Nursing staff, anesthesia technicians, respi-
ratory technicians, and biomedical engineers.
3. Competent operating room support staff. Biomedical engineers, infection
control, histopathology lab technicians, CSSD, housekeeping.
4. Safe Processes:
(a) Proper handover between clinical unit staff and operating room staff.
(b) Implementation of the WHO Surgical Safety Checklist.
(c) Proper infection control measures: proper scrubbing, proper attire, espe-
cially around the aseptic eld, adequate administration of prophylactic antibiotics (e.g., right antibiotics within 60min of skin incision), proper handling
of isolation patients.
(d) Preventative periodic maintenance (PPM) of all equipment/devices and peri-
odic inspection of HVAC/air exchanges.
(e) Postoperative plan of care: communicated among the surgical team, recov-
ery room (RR) staff, and receiving clinical unit staff.
5. Periodic Fire Safety Plan training.
6. Safe multidisciplinary team. Surgeons, anesthesiologist, nurses.
A. Alhawsawi and M. S. Macedo
What Do WeMean By aSafe Healthcare Professional (Surgeon,
Anesthesiologist, Scrubbed Nurse Circulating Nurse)?
Safe Surgeon
(PRE-OP Phase)
• Listens carefully to the patient and answers his/her questions.
• Involved personally in making the diagnosis.
• Performs proper “informed consent”: indications, description, potential compli-
cations, and provides an alternative treatment.
• Prepares well: pre-anesthesia consultation, reviews the images, reviews the anat-
omy, reviews the OR readiness (instruments, equipment, sutures, blood products
availability).
• Meets the patient in the pre-op (holding area) for reassurance, answers any ques-
tions the patient and/or family might have, reviews the appropriateness of
documentation.
(INTRA-OP Phase)
• Performs the WHO Surgical Checklist.
• Discusses the effective plan with the team: anesthesia, surgical, and nursing.
• Scrubs well: the operative site, his/her hands/arms, and his/her assistants.
• Performs proper surgical techniques: handles tissues well, adequate hemostasis,
good exposure, good illumination, aseptic technique (right operative theater
attire), safe handling of sharps.
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• Effective communication: with an assistant (explaining What, How, Why When,
Who), with anesthesia (proactive communication, especially consequential steps
in the procedure, for example, any steps that might result in physiological/hemodynamics changes); with the nursing staff: clear and proactive communication
with both scrubbed and circulating nurses.
– Divides the Procedure into Three Phases:
Beginning (starts with the skin incision): incision and opening.
Middle (starts with getting access to the surgical eld): the actual
procedure.
End (starts with the onset of closure): restoration of anatomic barriers, for
example, closing fascia and skin.
(POST-OP Phase)
• Proper documentation: operative note, labeling of the specimen (histopathology,
microbiology).
• Leaves the OR with the patient to recovery room (RR) to observe for any imme-
diate postoperative complications.
• Discusses (open and transparent communication) the outcome of the procedure
with the patient family shortly after the procedure.
• Observes the patient for any late postoperative complications (until discharge
from hospital).
• Available for any emergency or assign another competent surgeon in case he/she
is not available.
Safe Anesthesiologist
(PRE-OP Phase)
• Establishes pre-anesthesia clinic (PAC).
• Listens carefully to the patient and answers his/her questions in PAC.
• Performs proper preoperative risk assessment and/or optimization at PAC: ASA
classication, airway assessment.
• Discusses the risks and benets of anesthetic option and pain management strat-
egy at PAC.
• Performs nal patient assessment in the pre-op (holding area) to rule out any
reasons for cancellations and/or postponement.
• Prepares well: makes sure anesthesia machines are safe, the anesthesia team and
medications are ready, blood products available, appropriate IV (lines, uid)
available.
(INTRA-OP Phase)
• Performs the WHO Surgical Checklist.
• Discusses the anesthesia plan with the team: anesthesia, surgical, and nursing.
• Proper procedures techniques: aseptic technique, ultrasound-assisted catheter
(central line—arterial line) insertion, difcult airway set in OR (if needed).
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A. Alhawsawi and M. S. Macedo
• Continuously monitors and documents the physiological/hemodynamics status
of the patient.
• Effective communication: with an assistant (explaining What, How, Why, When,
Who), with the surgical team (proactive communication, especially consequential steps in the procedure, for example, any actions that might result in physiological/hemodynamics changes); with the nursing staff: clear and proactive
communication with circulating nurse.
(POST-OP Phase)
• Proper airway management.
• Leaves the OR with the patient to recovery room (RR) to observe for any imme-
diate postoperative complications.
• Proper handover of the patient to the RR staff.
• Continuously observe the patient in the RR for airway, hemodynamics, and pain
management.
• Assures proper documentation and safe discharge of patients from RR.
Safe OR Nurse
(PRE-OP Phase—Holding Room OR)
• Performs proper handover with the clinical unit nursing staff.
• Insures proper pre-op documentation: patient identication, informed consent,
PAC forms.
• Participates in the WHO Surgical Checklist.
• Reassurance to patients and family.
• Prepares the OR table, instruments (surgical team), and meds (anesthesia team).
• Coordinates with the surgical staff, anesthesia staff, and OR nursing staff to
ensure patient safety.
(INTRA-OP Phase—Scrubbed Circulating)
• Performs the WHO Surgical Checklist.
• Maintains sterile eld and aseptic instruments/OR table/surgical eld.
• Safe handling of instruments (scrubbed nurse) and prompt OR circulation (circu-
lating nurse).
• Effective communication: with surgical team (proactive communication, espe-
cially consequential steps in the procedure, for example, any actions that might
result in physiological/hemodynamics changes); with the nursing staff: clear and
proactive communication with circulating nurses.
• Effective implementation of counting policy (sponges, instruments, etc.).
(POST-OP Phase—Scrubbed Circulating)
• Maintenance of the surgical eld sterility until the patient is extubated and/or
leaves the room.
• Leaves the OR with the patient to recovery room (RR) to observe for any imme-
diate postoperative complications.
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• Proper labeling and documentation.
• Proper handover of the patient to RR staff.
• Proper handling of instruments with CSSD staff.
In addition to the above traits and competencies that OR team members should
observe to maintain patient safety, the following are common safety competencies
that are instrumental to be part of the conduct of OR multidisciplinary team
members:
1. Patient advocacy: patient safety is rst, second, third…and last!
2. Clinical risk management.
3. Speak–up. Responsibility to speak up and inform the OR leadership, in case of
any risky behavior by any of the team members.
In 2006, the American College of Surgeons (ACS) published an article about the
seven main crew resource management (CRM) principles that the OR environment
should learn from the aviation industry. These seven CRM Principles are:
1. Command. Even though the OR should have a teamwork environment, in the
end, one nal person must be the decision-maker who should accept responsibility and accountability for their team’s actions.
2. Leadership. Leaders must be willing to allow team members to exercise their
rights and responsibilities to ensure a safe and positive outcome. Although there
is only one commander, any member of a team can show leadership. Surgeons
who encourage teamwork are MORE respected.
3. Communication. Many studies have shown that poor communication is impli-
cated as a root cause for many medical errors.
4. Situational awareness. A safe and effective leader understands the uidity and
complexity of the OR and is always thinking ahead (What if…happened?) and
involving the entire team members.
5. Workload management. Stafng and working hours could lead to stress/over-
work and consequently, could jeopardize patient safety.
6. Resource management. Making sure ALL resources (human, nancial, equip-
ment, medications) are used toward improving quality and patient safety.
7. Decision-making. Collaborative, unilateral, and consultative, which is the most
effective in high-performance teams. A leader must avoid analysis paralysis.
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Crew Resource Management Approach, Human Factors,
andResilience
The main goal of CRM training is to enhance cognitive and interpersonal skills that
are crucial to maintain situational awareness, solve problems, and make decisions
within a team, in addition to a set of communication skills and a variety of behavioral approaches. The focus is on how to apply these skills to effectively manage
resources within an organized system that will enhance the safety of related operations, with less focus on the team’s technical skills. In this approach, a at hierarchy
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A. Alhawsawi and M. S. Macedo
should be promoted; not by dismissing the role of the operations’ leader, but by,
respectfully, questioning authority, in a timely, specic, and constructive manner.
This is a critical aspect considering the number of incidents reported where crewmembers tried, unsuccessfully, to bring the captain’s attention to vital information,
resulting in disasters.
Even though CRM has been introduced by the aviation industry in response to
the Tenerife airport disaster in 1977, the principles that encompass this concept have
been widely applied in other industries where time-sensitive and crucial decisions
must be made constantly, such as nuclear, oil and gas, ship handling, railways transportation, healthcare, and others. The reason lies in the fact that CRM recognizes
that human errors, leader’s decision-making and leadership styles and communication failures are at the root of major errors, which is applicable to several areas other
than aviation.
To truly understand how the human-to-human interaction and the human-toenvironment interaction impacts safety and, thus, chances for error (be it patients or
workforce), CRM training is rooted on human factors engineering (HFE). HFE is a
scientic discipline that studies humans’ interactions with each other, and among
organizations and systems, in order to optimize personal well-being and system
performance [4]. The understanding of human factors and its dynamics within
safety will promote resilience within healthcare, which is the “intrinsic ability of a
system to adjust its functioning prior to, during, or following changes/disturbances
in order to sustain required operations under expected or unexpected conditions.”
[5] Until recently, the focus of healthcare institutions that were committed to
increasing levels of patient safety would be to identify processes that would fail at
some point, allowing for errors to happen. Their focus is, therefore, on “what are the
things that could go wrong.” With this approach, institutions would x these gaps
and decrease errors. Building a culture of resilience within healthcare allows for a
mindset shift from focusing on what goes wrong into focusing on “what goes right
and works well.” One must appreciate that in addition to the average 10% of cases
that result in adverse events, the remaining 90% of cases result in safe care. So, what
happens within healthcare that ensures safe care? The key is the capacity of healthcare professionals to be resilient and focus on what works well instead of stressing
over what went wrong. This mindset can reduce stress and emotional fatigue, which
will positively impact patient care [6]. This daily mental exercise, where clinicians
strive to understand on how the provision of care succeeds most of the time rather
than on why it occasionally fails, is an important facilitator for CRM principles
implementation, where the understanding of human factors engineering impact on
patient safety is at its root.
“The human brain is a complex organ with the wonderful power of enabling man to nd
reasons for continuing to believe whatever it is that he wants to believe”—Voltaire
Additionally, healthcare professionals must appreciate the impact of cognitive
errors, originated by cognitive biases, in the clinical decision-making process (diagnosis and treatment) so that strategies can be developed to mitigate the cognitive
decits that are intrinsic to the human nature. These can be inherent to the human
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evolutionary condition but could also be acquired throughout the person’s cognitive
development, with the additional impact of the working environment [7]. Regardless,
the source of biases, if not recognized, may have a negative impact on the decisionmaking process, which can lead to errors. Moreover, work conditions such as cognitive overload, sleep deprivation, and stress are factors commonly found among
operating room staff, which may compromise safe clinical-related decisions. To this
point, cognitive bias avoidance training has been suggested as a key strategy in
reducing diagnostic errors, [8] where its main goal is to mitigate the adverse effects
of cognitive biases in patient outcomes.
Flying is very safe. According to IATA, in 2018, 4.3 billion passengers (the
equivalent of more than half the world’s population), traveled safely on 46.1million
ights. Out of those 46.1million ights, there were only 62 aircraft accidents, which
led to 523 fatalities.
Compare these remarkable safety stats to healthcare, and you will understand
how challenging the patient safety situation is. At a global level, 64 million
disability- adjusted life years (estimated) are lost in the world, annually, because of
unsafe care, bringing patient harm related to adverse events as one of the top 10
leading causes of death and disability in the world. Moreover, evidence suggests
that 134million adverse events occur in low- and middle-income countries’ (LMIC)
hospitals, contributing to 2.6million deaths (the equivalent of 1 death per 11seconds!). In high-income countries, approximately 1in 10 patients is harmed while
receiving medical care, and about two-thirds of the global burden of adverse events
occur in LMIC.In the USA, 251,000 Americans die from medical errors each year.
This is equivalent to more than 680 patients dying each day from medical errors,
making adverse events the third leading cause of death, preceded only by cardiovascular diseases and cancer [9]. In England, 3.6% of deaths in acute hospitals happen
due to the wrong provision of care, while one incident of patient harm is reported
every 35s.
There are many similarities shared between the operating room (OR) and an
airplane cockpit: both pilots and surgeons require advanced skill sets to perform
their duties, hierarchy is important in both environments, and safe outcomes are
dependent on effective communication among various team members. Because
aviation is known as an ultra-safe industry, it has been an inspiration to many in
healthcare to look at some of the analogies between the two sectors and try to draw
some lessons learned to improve patient safety. One of the areas that received much
attention lately is crew resource management (CRM).
The concept of CRM originated in 1979 within the U.S.National Aeronautics
and Space Administration (NASA), which underwent a workshop to understand the
root causes of aviation accidents [10]. The overall conclusion was that human factors, not technical ones, played a pivotal role in air trafc accidents. CRM focuses
on three primary measures, or the error troika: (1) Avoidance of errors (prevention).
(2) Trapping of errors before they are committed (early recognition). (3) Mitigation
of consequences emanating from errors [11]. It is noteworthy that 2years before the
establishment of CRM, in 1977, the world’s worst aviation disaster to date (Tenerife
accident) took place. That accident involved the collision of two Boeing 747
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A. Alhawsawi and M. S. Macedo
airplanes and claimed the lives of 583 people. One of the many factors that resulted
in that preventable tragedy was the absence of at hierarchy in the cockpit, as it was
evident that the First Ofcer of one of the Boeing 747 airplanes (KLM Airlines) was
aware of the situation but could not challenge the Pilot in Command.
CRM is about empowering all crew members to promote ight safety. Due to the
ongoing efforts in the healthcare system to improve patient safety, CRM received
more interest by healthcare safety experts as an attempt to learn from other industries. The efforts to apply CRM principles in healthcare started in the early 1980s (a
few years after the establishment of CRM in aviation), in anesthesia as a crisis
resource management tool [1].
Given the similarities between the conditions in the airplane cockpit (aviation)
and the operating room (healthcare), there is growing interest recently among some
surgical leaders to adopt CRM principles to improve the safety of patients in the
preoperative phase.
Here Is Our Suggested Approach toImproving Perioperative Safety
At the Saudi Patient Safety Center, we rmly believe that the sterility of the operating room should not only refer to its degree of germs-free physical environment, but
also to its degree of cleanliness of distractions and interruptions that may impact the
safety of the procedure being performed, and thus the safety of patients and the
healthcare team. While several reports apply the “sterile cockpit” principles from
aviation into specic isolated procedures in healthcare, such as medication delivery,
[12] little has been found regarding the mapping of the “sterile cockpit” concept to
the journey through which patients and surgical teams ow while performing an
invasive procedure; be it in the operating room or any other related invasive procedural setting. Considering the high risk for communication errors, misunderstanding of individuals’ roles within a team, noise, and mishandling of safe transitions
within the perioperative phase, SPSC proposes the following mapping of the “sterile
cockpit” concept throughout the intraoperative journey, where the CRM principles
are applied, with the main focus on communication levels to ensure higher levels of
safety in OR (Fig.15.1).
Fig. 15.1 Sterile Operating Room—a framework aligned with the Sterile Cockpit concept
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In this proposed framework, we acknowledge that, within healthcare (as in aviation), communication failures have a high chance to occur, making it one of the
leading causes for adverse events in the health industry, as reported by the Joint
Commission 2004–2011, where it highlights that 70% of sentinel events were due
to communication errors [13]. These failures may be presented more often within
the healthcare industry, as there is a higher variety of staff with specic skills, disruptions, and noise in addition to a higher rate of transitions of care within the
patient’s journey, making safe transitions, within OR, a focus to ensure patient
safety, safeguarding, thereby, a positive experience from the point of admission,
throughout the surgical procedure until discharge. Teamwork and culture to open
communication are, therefore, vital elements within the OR setting.
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The Sterile OR framework andCRM Principles
The Crew Resource Management main principles are command, leadership, communication, situation awareness, workload management, resource management,
and decision-making. In order to ensure high levels of safety in OR, these principles
must be present at all times, every 60s/min. Similar to what is applied in aviation,
the intraoperative journey has been divided into three phases: before anesthesia
induction (take-off), procedure (cruising), and after procedure (landing). In the
same way that there are clear periods of restricted communication throughout these
phases in aviation, it is proposed that similar periods of restricted communication
are applied within the OR setting according to the level of criticalness. In view of
this, an extra layer was added to highlight areas that are more critical and thus,
prone to higher degrees of errors and link these to the levels of communication
allowed during these periods.
The Sterile Cockpit
In aviation, during the phases of take-off and landing there are three periods (below
10,000feet) of restricted communication: during taxiing (before takeoff and after
landing), where only safety-related issues are to be communicated. On departure,
the sterile cockpit starts when all doors are closed and ends when the seat belt sign
is switched off after takeoff. On arrival, the sterile cockpit period starts with the
cabin preparation for landing and it ceases when the aircraft arrives at the terminal.
These periods are characterized by restricted communication, where the cockpit can
only have safety-related communications. Some examples of issues that can be
communicated are, but not limited to, smoke or re anywhere in or outside the aircraft, seat belt related info and/or turbulence situation, problems related to securing
the cabin for landing, and any other issues that may prevent a safe takeoff or landing
procedure (Figs.15.2 and 15.3).
Within these “safety-related issues only” periods, are “no contact” periods,
characterized by a complete communication restriction. These periods are very critical and coincide with the highest workload/risk segments of takeoff and landing
and operate between the commencement of the takeoff roll to gear-up and during
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Fig. 15.2 Communications during the Sterile Cockpit is restricted to safety-related communications only
A. Alhawsawi and M. S. Macedo
Fig. 15.3 Take off and landing phases are considered “Sterile Cockpit” phase whereas cruising
altitude is considered non-Sterile Cockpit phase
landing, between gear-down until the runaway is vacated or the aircraft has stopped
on the runaway. Contact with the cockpit crew during this period is not permitted,
as distractions may disrupt the crew at a critical time. During these critical ight
phases, no crewmember should perform or ask to perform any non-essential activities other than those required for the safe operation of the plane. During cruising
ight phase, all type of communications is permitted (Fig.15.4).
Before Anesthesia Induction phase: This is the OR phase that immediately precedes the procedure and is considered a critical phase. During this period, only
safety-related issues should be communicated (similarly to what is seen during taxiing in aviation) and is when the rst component of the WHO Surgical Safety
Checklist (WHO SSC) is applied by at least the nurse and the anesthetist (Fig.15.5).
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