PATIENT SAFETY

Analyzing Human Factors Affecting Surgical Patient Safety Using Innovative Technology

Creating a Safer Operating Culture

Creating a Safer Operating Culture

Creating a Safer Operating Culture

Published on

September 1, 2022

Journal of Patient Safety

Anne Sophie Helena Maria van Dalen, James J Jung, Els J M Nieveen van Dijkum, Christianne J Buskens, Teodor P Grantcharov, Willem A Bemelman, Marlies P Schijven
Anne Sophie Helena Maria van Dalen, James J Jung, Els J M Nieveen van Dijkum, Christianne J Buskens, Teodor P Grantcharov, Willem A Bemelman, Marlies P Schijven
Anne Sophie Helena Maria van Dalen, James J Jung, Els J M Nieveen van Dijkum, Christianne J Buskens, Teodor P Grantcharov, Willem A Bemelman, Marlies P Schijven

Overview

This cross-sectional study used a medical data recorder (MDR) to assess intraoperative safety threats and resilience support events during 35 standard laparoscopic procedures. The research aimed to identify frequently discussed safety and quality improvement issues through structured postoperative multidisciplinary debriefings. Using the Systems Engineering Initiative for Patient Safety model, the study analyzed MDR outcome data, focusing on categories such as person, tasks, tools and technology, physical and external environment, and organization.

The results showed an average of 52.5 relevant events per surgery, with both resilience support and safety threat events most commonly related to interactions between persons. Communication failures emerged as the primary topic during team debriefings. The study concluded that patient safety threats were most frequently associated with communication, teamwork, and situational awareness. To enhance operating room safety culture, the authors recommend that educational and quality improvement initiatives focus on training the entire operating team, fostering a shared understanding of relevant safety issues.

Results

A mean (SD) of 52.5 (15.0) relevant events were identified per surgery. Both resilience support and safety threat events were most often related to the interaction between persons (272 of 360 versus 279 of 400). During the debriefings, communication failures (also category person) were the main topic of discussion.