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15 Implementing Crew Resources Management Principles to Improve Perioperative…
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Fig. 15.4 “Sterile Operating Room” Concept: Before, during, and after the procedure
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Fig. 15.5 WHO Surgical Safety Checklist
Once the patient is under anesthesia and the surgical team initiates the procedure
phase, the critical phase continues as the second component of the WHO SSC is
applied just before skin incision. Here, the team composed by the nurse, the anesthesiologist, the surgeon, and other allied healthcare professionals performs time
out. Time out reects the CRM brieng and debrieng, incorporated by WHO,
while developing the SSC.During this brieng period, the elements of CRM (com-
mand, leadership, communication, situation awareness, workload management,
resource management, and decision making) are determined (Fig.15.6).
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Fig. 15.6 The phase before anesthesia induction
A. Alhawsawi and M. S. Macedo
Furthermore, it is known that factors such as substance abuse, mental illness,
physical illness, fatigue, exhaustion, and other related issues are associated with
medical errors [14]. During this segment of the perioperative journey, every surgical team member (particularly the surgeon) must be aware of his/her ability to
perform safely. The mnemonic IMSAFE developed by the Federal Aviation
Administration, initially created to assess the pilot’s physical and emotional condition to operate, has been adopted among surgeons. SPSC strongly recommends
it to be applied across the surgical team, as the untness of one member will
affect the safety of the procedure as a whole. At this point, during this phase,
each individual must assess him/herself and each other by checking on the following IMSAFE aspects: Illness–is any team member suffering any acute or
chronic illness that may distract him or her from the operation?; Medication–is
any team member taking any medications that could affect performance or judgment?; Stress–is any team member under signicant stress from events in his or
her professional or personal life?; Alcohol–is any team member under the inuence of alcohol?; Fatigue–have the team members had adequate rest and nutrition? (This is of particular relevance to the surgeon.); Emotion–is any team
member emotionally competent to operate? There might be occasions where an
individual person may not be able to recognize that he or she is not t to carry
out related duties, and therefore it is vital that the team members feel empowered
to raise concerns.
Similar to what occurs within aviation, it is important that every team member of
the surgical team understands and is aware of what situations are considered “safetyrelated issues.” Due to the variety and complexity of cases, it is up to the surgical
team to decide and agree upon what denes “safety-related issues.” Unless all the
surgical team members are in the loop regarding this point, effective responses to
raised concerns won’t be possible, thereby posing a risk to patient safety.
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Procedure phase: This phase is further divided into sub-phases that are considered non-critical and critical. The Procedure phase corresponds to the “cruising
phase” of the sterile cockpit concept. During non-critical phases, all kinds of communications are allowed. The denition of which procedural phases are non-critical
and critical should be determined, as much as possible, during the brieng phase,
where the surgical team should be aware (situational awareness) of potential risks
that are associated with the interventions within the procedure. Situational awareness is highly important, as it guarantees that the team members share a mental
model of the procedure and its potential risks, allowing for effective decisions and
actions that may eventually have to take place in a short period of time. In addition,
it helps to determine what crucial moments are expected within the procedure phase
that may require full attention from the surgeon where no contact should be made,
and the team is aware in which exceptional situations the “no contact” rule may be
overridden. Once again, in order for the shared mental model to be created, adequate communication is key. The operating room staff, regardless of their role or
their hierarchal position, are empowered to say something if they see something. A
“speak up” culture, where each team member feels comfortable to raise concerns, is
vital and must be encouraged at all times, as postoperative complications and fatal
errors have been associated with lack of sharing vital information. This fact highlights the impact of effective teamwork within the surgical team for safe care
(Fig.15.7).
After-procedure phase: This phase is characterized by debrieng, and, similarly
to the “take off” period (sterile cockpit) and the before anesthesia induction phase
(sterile OR), only safety-related issues should be communicated. During this period,
the last component of the WHO Surgical Safety Checklist (WHO SSC) is applied
by at least the nurse, the surgeon, and the anesthetist. Before the patient leaves the
operating room, the debrieng will allow for team members to raise safety concerns, if any.
Fig. 15.7 The phase during the surgical procedure
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Fig. 15.8 The phase after the surgical procedure
A. Alhawsawi and M. S. Macedo
Suggested Strategies fromCRM
In a nutshell, and additionally to what was previously suggested, operating rooms
and other settings where invasive interventions take place will benet from implementing aviation strategies such as:
• cross-checks
• readback
• “two-challenge rule,” when a person has been challenged twice and has failed to
respond accordingly, anyone from the team can override this person
• peer monitoring
• briengs, dening operating procedures and standards
• recognition of fatigue as a factor in performance
• regular “check rides” in the form of assessment in a simulator
• blame-free reporting culture
• use of checklists for the team to stand back and appraise procedures
• direct eye contact, introducing each other, using non-judgmental words
• putting safety before self-esteem [14] (Fig.15.8).
Safe Staffing intheOperating Room
Adequate stafng in the operating room is vital to ensure safe delivery of care. The
OR leadership must ensure that the right number of staff with the right skill mix is
assigned to each surgical team at all times. International and national regulatory
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bodies across the globe recognize the need to establish minimum acceptable nursing
and other allied healthcare professionals’ ratio standards to provide safe patient
care. Hospitals with poor patient outcomes are found to have unsafe work environments, with insufcient nursing and allied healthcare staff. The estimation of the
appropriate number of staff and proper skill mix must be based on evidence and is
usually informed by the professional associations of each specialty. The Association
of periOperative Registered Nurses (AORN) [15] recognizes that the primary focus
of the perioperative nurses and other healthcare professionals within OR is patient
safety. Thus, adequate personal stafng plan must be developed to meet the safety
needs of both the patient and the healthcare professional. SPSC in collaboration
with the International Council of Nurses released a White paper on Nurse Stafng
Levels For Patient Safety And Workforce Safety in 2019, [16] which is a high-level
advisory framework on the regulatory landscape, and recommendations that must
be in place for optimal nurse-stafng ratios and skill mix that will serve as the foundation for a culture of safety. Moreover, it is important to take into consideration
factors that have a direct impact on the safe provision of care within the OR.The
AORN establishes evidence-based calculation methodologies that facilitate the
decision on adequate stafng for the OR.Factors to take into consideration while
establishing OR staff ratios are hours of operation (dened by the department),
hours required to cover off-shift schedules (holidays, nights, weekends), urgent procedures, the number of OR rooms, historical data regarding minutes and hours of
service, procedure volumes, and mix and technology requirements, in addition to
the effect that extended shift hours have in staff performance and consequently inpatient safety.
To ensure safe nursing and other allied healthcare professionals care, one
must recognize that there’s no “one size ts all” approach to this. The nurse-topatient ratio may vary across OR suites as well as within the same OR suit
throughout the same procedure and are thereby not rigid. Also, while determining safe nurse-to- patient ratios, one must consider the overall availability of
ancillary staff/allied health professionals such as nursing aids, licensed practice
nurses (LPNs), and technicians. Often, the recommended ratios are put forward
based on the premise that a full complement of ancillary and support staff is present at all times during each shift within a unit. The bottom line to determine
nurse-to-patient ratios or other healthcare professionals must be always the
safety of patient care and the safety of the professionals providing care, and not
the number of staff available.
Given this, SPSC put forward recommendations for RN-patient ratios in OR as
follows (Fig.15.9):
** Additional staff members (technicians, ancillary staff), with suitable and adequate competencies, must be used to meet safe stafng [15].
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A. Alhawsawi and M. S. Macedo
Fig. 15.9 Safe Nurse: Patient Ratios
Conclusion
In the healthcare industry, near misses and actual adverse events may go underreported due to the premise that errors are “part of the business.” Moreover, healthcare
professionals may not feel comfortable reporting, due to an institutionalized blaming culture where errors are seen as consequences of individual malpractice as
opposed to a system failure, and also due to an inated sense of pride as well as fear
of legal consequences. To shift this trend, it is vital that healthcare professionals
understand the value of reporting errors as much as near misses as a valuable learning tool. Similar to the aviation industry that implemented the Condential Human
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Factors Incident Reporting Programme, surgical teams introduced the Condential
Reporting System in Surgery. Reporting and learning systems such as this have
been proven to not only bring to light errors and near misses that are analyzed so
they won’t happen again, but also to promote a just culture.
Another method proven to be efcient in identifying behaviors and actions with
high potential for errors is to involve expert observers in the surgical rooms during
procedures. This approach was established by the aviation industry known as “Line
Operations Safety Audit” or LOSA.It identies not only the actions that may put
patient safety at risk, but also the risk factors or the sources for these potential
errors. LOSA is thereby a valuable strategy to identify conscious or unconscious
protocol violations, failures in communication, and poor decision-making processes, by direct observation of the surgical team, allowing for focused implementation strategies aimed at managing human-error factors of the identied risks.
The failures found in the perioperative journey are not only highly prone for serious or fatal adverse events, but also highly preventable. Any approach that aims at
preventing the gaps and/or failures in the process will improve the reliability of
surgical care and consequently improve safety levels for surgical patients and surgical teams [17].
Sterile OR Made Easy—Supporting Framework for Surgical Teams
Given the relation between aviation concepts and healthcare industry, SPSC proposes the following framework to be used as a guiding tool by each surgical team
before commencing a procedure:
1. Divide your intervention into segments: before (takeoff), during (cruising), and
after (landing).
2. Identify which tasks belong to each segment for clarity.
3. Insert CRM principles as: brieng, debrieng, at hierarchy, situation awareness.
4. For each segment, identify:
(a) Critical phases: where safety-related issues only take place. Here identify
what are considered safety-related issues.
(b) Non-critical phases: where any type of communication can take place
(c) No-contact phases, if any: where no communication of any kind is allowed
References
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modelling strategy based on available data. Lancet. 2008;372(9633):139–44.
2. WHO guidelines for Safe Surgery, 1st ed. Geneva: World Health Organisation; 2008.
3. Pearse RM, Moreno RP, Bauer P.Mortality after surgery in Europe: a 7 day cohort study.
Lancet. 2012;380(9847):1059–65.
4. Crew Resource Management, LLC. https://www.criticalcrm.com/topics
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6. UNC Health. Enhancing resilience, building a stronger patient safety culture. http://news.unchealth-
care.org/empnews/2015/oct- 1/enhancing- resilience- building- a- stronger- patient- safety- culture
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7. Croskerry P, Singhal G, Mamede S.Cognitive debiasing 1: origins of bias and theory of debiasing. BMJ. 2013;22(Suppl 2):ii58–64. https://doi.org/10.1136/bmjqs- 2012- 001712.
8. Kapur N, Parand A, Soukup T, Reader T, Sevdalis N.Aviation and healthcare: a comparative
review with implications for patient safety. JRSMed Open. 2015;7(1):2054270415616548.
https://doi.org/10.1177/2054270415616548.
9. Makary MA, Daniel M. Medical error–the third leading cause of death in the
US.BMJ. 2016;353:i2139.
10. Helmreich RL, Merritt AC, Wilhelm JA.The evolution of crew resource management training in commercial aviation. Int J Aviat Psychol. 1999;9:19–32. https://doi.org/10.1207/
s15327108ijap0901_2.
11. Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH.Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ
Med. 1992;63(9):763–70.
12. Federwisch M, Ramos H, Adams S.The sterile cockpit: an effective approach to reducing
medication errors? Am J Nurs. 2014;114:47–55.
13. Joint Commission. Improving patient and worker safety: opportunities for synergy, collaboration and innovation. Oakbrook Terrace, IL: The Joint Commission; 2012. p.171.
14. Stripe SC, Best LG, Cole-Harding S, Field B, Talebdoost F.Aviation model cognitive risk
factors applied to medical malpractice cases. J Am Board Fam Med. 2006;19:627–32.
15. AORN.AORN position statement on perioperative safe stafng and on-call; 2014. https://
www.aorn.org/- /media/.../posstat- personnel- safe- stafng- on- call- practices.pdf. Accessed
May 2019.
16. Saudi Patient Safety Center; International Council of Nurses. Nurse stafng levels for patient
safety and workforce safety. SPSC and ICN white paper. Riyadh, Saudi Arabia; 2019. spsc.
gov.sa and icn.ch.
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A. Alhawsawi and M. S. Macedo
Peer Review ofPerioperative Adverse
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Events
LydiaR.Maurer, ElizabethMort, andHaythamM.A.Kaafarani
Introduction
“Every surgeon carries about him a little cemetery, in which from time to time he goes to
pray, a cemetery of bitterness and regret, of which he seeks the reason for certain of his
failures.”—René Leriche [1]
“To effect improvement, the rst step is to admit and record the lack of perfection.”—
Ernest A.Codman [2]
By taking a patient to the high-risk environment of the operating room, the surgeon often develops a special and personal bond of trust with the patient. As such,
patient mishaps often take a personal toll on surgeons. Critically analyzing complications and adverse events to prevent their reoccurrence has become a key part of
training and is central to the discipline of surgery. While there are many described
and practical ways that perioperative adverse events could be analyzed, a peer
review discussion in the morbidity and mortality (M & M) conference is the standard in almost all surgical specialties. The profession’s commitment to learn from
adverse outcomes has evolved over time and is incorporating tools from safety science and is encouraging quality improvement. These advances should both accelerate needed improvements and give surgeons the tools to provide better care and to
contribute more effectively with systems improvements.
16
L. R. Maurer
Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
E. Mort (*)
Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
e-mail: emort@partners.org
H. M. A. Kaafarani
Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care,
Massachusetts General Hospital, Boston, MA, USA
© 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_16
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L. R. Maurer et al.
Morbidity andMortality Conference
The history of the M & M conference is often traced back to Dr. Ernest Emory
Codman, a surgeon at the Massachusetts General Hospital in the late nineteenth and
early twentieth centuries [3]. He created the “end result” concept, or the idea that
surgeons should follow their patients to determine the outcome of their treatment
and/or any adverse effects or complications that occurred as a result of the operation. He was a controversial gure who also believed in public reporting of outcomes, an unpopular concept back then among surgeons and hospital leaders.
However, despite the resistance to public reporting, analyzing adverse events, or
what he termed as the “end result” idea, was adopted in many hospitals and eventually evolved into what is now known as M & M.An additional sentinel text on error
and the culture of surgical practice was Charles Bosk’s book Forgive and Remember,
in which he dissects the role of error in surgical culture. He refers to the M & M
conference as a place where the responsible parties take responsibility for the error,
and other clinicians offer comment and often forgiveness, and do so in a way that
everyone will remember and not repeat the error [4]. M & M provides an environment where errors can be addressed and analyzed directly among peers in a memorable way that all can learn from them, but in the end the surgeon gains the support
of his or her peers to move forward, learn from it, and keep treating patients safely.
The M & M conference is currently a well-established feature for quality assurance in most surgery and anesthesia departments, but its structure remains variable.
Essential components of the M&M conference format are condentiality and the
allowance of candid discussion away from fear of medicolegal repercussions. This
so-called peer review privilege is legislated at the state level and its intent is to promote candid conversations among peers without fear of the content of the conversations being discovered in the context of medical malpractice proceedings [5]. Any
individuals involved in managing these sessions should familiarize themselves with
the laws in their state and ensure that the proceedings are managed in keeping with
their institution’s policies. While the existence of a regular M & M conference is a
required feature for accreditation by professional societies, there is no set format that
must be followed. There is often one central M & M conference for the department
of surgery, and in many cases individual divisions (i.e., trauma, transplant, thoracic)
will have their own division-specic conferences. Surgeons voluntarily submit their
perioperative complications, and these are discussed in a peer feedback- and- review
format to identify what went wrong and opportunities for improvement. For example, in an academic training setting, senior residents and fellows might present a brief
synopsis of the case of interest and will eld questions regarding the operation and/
or the management of the patient from the other faculty and trainee surgeons in the
audience. In some institutions, a select number of M & M presentations (a small
number of the total submitted per week) are presented for group discussion, while in
other institutions every complication is presented. The format of the discussion varies among institutions from an informal discussion led by the faculty surgeon responsible for the patient to more formalized discussions including presentation of relevant
literature and, occasionally, more formal root cause analyses.
Complications are often categorized into preventable and unpreventable, or gradations of preventability. Lessons learned and opportunities for improvement are
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