OR Briefings May Reduce Wrong-Site Surgery Blunders

January 24, 2007

BALTIMORE -- A bit of pre-op prophylactic palaver after the patient is anesthetized is being advocated as a way to prevent wrong-site surgery.

BALTIMORE, Jan. 24 -- A bit of pre-op prophylactic palaver after the patient is anesthetized is being advocated as a way to prevent wrong-site surgery.

A simple two-minute pre-op huddle by operating room staffers should include such vitals as the names and roles of all team members, the operative plan, the familiarity with the procedure, and the potential issues for the case, recommended Martin A. Makary, M.D., M.P.H., director of the Center for Surgical Outcomes Research at Johns Hopkins, and colleagues.

At the same time, the lead surgeon should verify the patient's identity and the surgical site, and discuss other safety concerns with the team, wrote Dr. Makary and colleagues in the February issue of the Journal of the American College of Surgeons. The pre-op huddle became hospital policy at Hopkins last June.

"Cases of wrong-site surgery have gained considerable attention recently, and can be extraordinarily devastating to patients, families, caregivers, and institutions," noted Dr. Makary.

They investigators pointed out that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) identified "communication breakdowns" as the most common cause of wrong-site surgery.

In a review of nearly three million operations, the occurrence rate of wrong-site non-spinal operations was one in 112,994, reported Atul Gawande, M.D., M.P.H., and colleagues, at Brigham and Women's Hospital in Boston, in the April 2006 issue of the Archives of Surgery. "Wrong-site surgery is unacceptable but exceedingly rare, and major injury from wrong-site surgery is even rarer," Dr. Gawande and colleagues wrote.

They concluded, however, that various site-verification protocols in place in the institutions surveyed could have prevented only two-thirds of the wrong-site procedures.

At Hopkins, Dr. Makary and colleagues found that pre-surgical briefings, performed in the OR after anesthesia has been induced, but before the first incision has been made, can help to prevent wrong-site surgery.

The investigators studied the attitudes of OR personnel toward the utility of briefings and their ability to reduce the risk.

They administered a case-based version of the Safety Attitudes Questionnaire, developed at the University of Texas Center of Excellence for Patient Safety Research and Practice. The survey was administered to 147 surgeons, 59 anesthesiologists, 187 nurses, and 29 other OR staffers, both before the policy went into effect and three months after it had been in place.

The items on the questionnaire are meant to assess a caregiver's perception of coordination and awareness of the surgical site, with response options ranging from 1 (disagree strongly) to 5 (agree strongly).

The authors used multivariate analysis of variance (MANOV) to test for changes in overall caregiver assessments before and after the implementation of briefings, and the percentage of OR staff who agreed or disagreed with each question was recorded.

They found that frontline caregivers associated the use of briefings with a reduced risk for wrong-site surgery and with improved collaboration (F (6, 390) = 10.15, P