Patient Safety: Break the Silence

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Patient Care Services / Nursing

Patient Safety: Break the Silence Patient Safety: Break the Silence

Hope L. Johnson MSN, RN, CNOR

Lehigh Valley Health Network

, [email protected]

Diane Kimsey MS, RN, CNOR

Lehigh Valley Health Network

, [email protected]

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Johnson, H. L., Kimsey, D. (2012). Patient Safety: Break the SIlence.

AORN Journal, 95

(5), 591-601.

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Patient Safety: Break the Silence

HOPE L. JOHNSON, MSN, RN, CNOR; DIANE KIMSEY, MS, RN, CNOR

ABSTRACT

A culture of patient safety requires commitment and full participation from all staff

members. In 2008, results of a culture of patient safety survey conducted in the

perioperative division of the Lehigh Valley Health Network in Pennsylvania re-

vealed a lack of patient-centered focus, teamwork, and positive communication. As

a result, perioperative leaders assembled a multidisciplinary team that designed a

safety training program focusing on Crew Resource Management, TeamSTEPPS,

and communication techniques. The team used video vignettes and an audience

response system to engage learners and promote participation. Topics included using

preprocedural brieﬁngs and postprocedural debrieﬁngs, conﬂict resolution, and as-

sertiveness techniques. Postcourse evaluations showed that the majority of respon-

dents believed they were better able to question the decisions or actions of someone

with more authority. The facility has experienced a marked decrease in the number

of incidents requiring a root cause analysis since the program was conducted. AORN

J 95 (May 2012) 591-601. © AORN, Inc, 2012. doi: 10.1016/j.aorn.2012.03.002

Key words: patient safety, workplace culture, patient-centered focus, hospital survey.

mproving patient safety in the perioperative

ﬁeld requires creating a culture of safety in

which the patient always comes ﬁrst. To de-

velop such a culture, all staff members must un-

derstand the importance of good communication

and the need to focus on patient safety at all

times. In 2008, perioperative managers at the

Lehigh Valley Health Network (LVHN), a 988-

bed academic, community, Magnet® health sys-

tem located in eastern Pennsylvania, conducted

a culture of patient safety survey in the periop-

erative division. Members of the risk manage-

ment/patient safety department conduct this

type of patient safety survey annually to mea-

sure the organization’s safety culture. In 2008,

the data derived from this survey revealed a lack

of patient-centered focus, teamwork, and effective

communication. This prompted perioperative leaders

to take action. They assembled a multidisciplinary

team to examine the survey results, complete root

cause analyses (RCAs) after every event that

The Joint Commission would deem “serious” (eg,

retained foreign bodies, OR ﬁres, medication er-

rors, near misses for blood exposure), and de-

velop measures to enhance patient safety. The

team included staff members from perioperative

services; the education, anesthesia, and surgery

departments; and multimedia services. Team

members discussed ideas for a patient safety

training program that would include the use of

video vignettes and classroom lectures to educate

staff members.

ASSESSMENT PHASE

The team began by conducting a comprehensive

literature review to determine evidence-based best

practices to improve patient safety in the periop-

erative setting. Research has shown that teaching

doi: 10.1016/j.aorn.2012.03.002

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team-building and communication skills to periop-

erative staff members can improve safety and re-

duce patient death rates.

Educating staff mem-

bers raises awareness, improves communication

skills, and increases empowerment. The team fo-

cused its efforts on training members of the anes-

thesia, surgery and obstetrics/gynecology (OB/

GYN), and perioperative services departments.

This included more than 800 health care clini-

cians, ranging from physician level to allied

health care personnel.

As a general comparison, the team evaluated

the 2009 benchmarking database of the Agency

for Healthcare Research and Quality (AHRQ)

Hospital Survey on Patient Safety Culture,

which

indicated that although 79% of 196,462 health

care providers responded positively about the

teamwork in their units, only 62% responded pos-

itively about communication openness, and only

44% responded positively about hand offs and

transitions. The LVHN facility’s baseline survey

results indicated that only 43% of perioperative

staff members were willing to question or chal-

lenge authority. In addition, 53% of perioperative

staff members stated that they were afraid to

ask questions when something did not seem

right during a procedure. Several RCAs con-

ducted after sentinel events had occurred at the

LVHN facility cited a lack of communication

or failure of a staff member to voice concern as

contributing factors leading to the event. The

team chose to address staff members’ discom-

fort with speaking up and to provide tools to

enhance communication during difﬁcult or un-

usual events. Furthermore, team members

wanted to engage physicians and allied health

care providers in the process and invite open

communication in an environment in which

challenging authority would be welcomed.

The large number of staff members who needed

the training made use of certain teaching tools

(eg, return demonstration) impractical. The team

also determined that an interdisciplinary approach

would be far more effective than teaching in

individual silos. Additionally, the team recognized

the beneﬁt of real-time feedback with the goal of

raising staff members’ awareness of the concerns

of each group. To ensure compliance with train-

ing, the team made the course mandatory for all

providers who required credentialing. All partici-

pants who attended the course and completed the

postcourse evaluation would receive continuing

nursing education or continuing medical education

credits.

The team researched several established com-

munication enhancement programs while devel-

oping the presentation. They included education

about concepts and techniques from the Depart-

ment of Defense and AHRQ Collaborative’s

Crew Resource Management (CRM)

and

TeamSTEPPS®.

Several members of the plan-

ning committee attended a course focusing on

team building, and the information gleaned

from this course was a driving force in the

development of the ﬁnal LVHN course.

The decision to use the TeamSTEPPS ap-

proach was based on a 2010 multilevel evalua-

tion of the TeamSTEPPS training program con-

ducted by Weaver et al,

in which positive

results were demonstrated in an OR service

line. Weaver et al

evaluated a mixed-model

design with one between-groups factor (ie,

training or no training) and two within-groups

factors (ie, time period, team). The group

trained on TeamSTEPPS principles demonstrated

signiﬁcant increases in the quantity and quality of

presurgical procedure brieﬁngs and the use of

quality teamwork behaviors during procedures.

The perceptions of a patient safety culture and

teamwork attitudes also increased.

The LVHN multidisciplinary team members

decided that to have the greatest effect on training

attendees, they needed to use a combination of

teaching tools that focused the course on four

distinct areas:

 reasons for the presentation,

 CRM,

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 TeamSTEPPS, and

 communication techniques.

They decided to use videos, research, and internal

institutional anecdotes to present a variety of sup-

porting evidence to illustrate points. The team

believed that using videos of staff members in

vignettes would receive a more favorable recep-

tion than using professionally made stock videos.

The videos would incorporate the use of the tech-

niques the facility was presenting in OR suites

and holding rooms and would reﬂect the facility’s

policies and procedures. For example, the team

created vignettes that depicted use of The Joint

Commission’s required time-out

procedures, pre-

operative brieﬁng procedures, and postoperative

debrieﬁng procedures using members from the

anesthesia, surgery and OB/GYN, and periopera-

tive departments and media services. After editing

the video, team members linked the videos into

the overall presentation at key points.

The program was quite lengthy, so to prevent

audience detachment and to establish the partici-

pants’ baseline knowledge, the presenters incorpo-

rated an audience response system (ARS), oper-

ated through small handheld voting devices that

would be used to poll the audience at various

times during the presentation. The ARS would

allow the presenters not only to understand the

demographics of the attendees in the room, but

also provide feedback on audience comprehen-

sion. Questions could be posed to the audience

after a particular section of the presentation to

ensure that delivery of the information was clear

and well received.

ACTION PHASE

After months spent on program preparation, a

team of perioperative directors and chairs and

vice chairs from the anesthesia and surgery de-

partments presented the three-hour program titled

“Enhancing Perioperative Teamwork to Improve

Patient Safety.” The program included an intro-

duction and background information about the

reasons for the program and a description of

CRM, positive team dynamics, and communica-

tion tools. Management-level staff members were

asked to present the program to ensure organiza-

tional and departmental buy-in for the program.

The program objectives were for participants to

be able to

 use the National Patient Safety Goals

to cre-

ate an optimal environment of care and safety

for patients;

 recognize the patient as the most important

person in the OR;

 articulate effective communication and team-

work techniques to decrease the incidence of

negative surgical outcomes;

 recognize and implement techniques for effec-

tive communication among staff members in

the anesthesia, surgery and OB/GYN, and

perioperative services departments; and

 create a culture of safety to increase positive

patient and employee satisfaction.

Presentation Introduction

Each attendee was presented with a handheld

ARS remote. The course began with questions to

help identify the demographics of the audience

and their thoughts regarding the current state of

the OR culture. The attendees were asked to iden-

tify their title, who they perceived to be the most

important person in the OR, and what their ﬁrst

response would be if they saw an error in the OR.

The ARS voting helped participants engage in the

program, demonstrated the multidisciplinary qual-

ity of the audience, and provided baseline infor-

mation about the attendees’ comfort levels regard-

ing speaking out for patient safety. Figure 1 is an

example of an audience response using the ARS.

The presentation continued with a video that

portrayed a patient and family experience with

many levels of risk and error. For instance,

 a patient was instructed by a health care pro-

vider to schedule a follow-up appointment in a

week, but the receptionist indicated that practi-

tioners were not available at that time and

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gave the patient an appointment for three weeks

later;

 an attending surgeon did not wait for intuba-

tion to be completed before beginning a pro-

cedure and then verbally attacked the anesthe-

sia care provider for delaying the procedure;

 the circulating nurse was distracted with a cell

phone call for the surgeon and inadvertently

placed the wrong medication on the back table;

 a patient did not speak English very well but

no translator was offered.

After viewing the video, presenters helped audi-

ence members discuss what they had seen in the

video. The presenters highlighted important

points, including

 patients should always come ﬁrst,

 staff members should be focused on the pa-

tient’s safety at all times,

 good communication skills are important,

 OR hierarchy must never trump safety, and

 staff members must feel comfortable and em-

powered to be assertive whenever necessary.

Crew Resource Management

Aviation and medicine have much in common in

that they both are complex ﬁelds and both involve

high risk.

A major part of the presentation, there-

fore, focused on CRM techniques developed by

the aviation industry to decrease risk by reducing

preventable human errors.

Two videos that por-

trayed ﬂights in which things go terribly wrong

were included in the presentation. The ﬁrst video

ends in disaster, and the second video ends well.

The premise is that because humans are not per-

fect, mistakes will happen. The difference be-

tween a mistake resulting in a negative outcome

versus a positive outcome is teamwork and how

the people involved communicate with one an-

other. Effective teams operating in a safe environ-

ment can prevent errors from causing harm to the

patient.

Health care is inherently risky; the technology

is complex and ever-changing, staff members are

under time constraints, levels of competency vary,

and every patient encounter is different. These

Figure 1. Example of an audience response using the audience response system. Printed with permission

from Lehigh Valley Health Network Cedar Crest, Allentown, PA.

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issues emphasize the need for strong, cohesive

teams. Presenters discussed essential team ele-

ments, such as having a shared purpose and com-

mon goals, recognizing the interdependence of

team members’ actions, being accountable to one

another and to the patient, the value of a collec-

tive effort, and the need for clear and deﬁned

leadership.

Presenters then compared the traditional

leader with the situational leader and explained

how leadership can shift depending on the situ-

ation. The traditional leader oversees team ac-

tivity, articulates goals, facilitates decision

making, and promotes teamwork. The situa-

tional leader varies depending on the task at

hand.

For example, during a time out, the cir-

culating nurse is typically the leader. In an air-

way emergency, the anesthesia professional has

the leadership role. At the end of this section of

the presentation, attendees used their ARS de-

vices to indicate their understanding of the im-

portance of effective teamwork. Comprehension

of the course content was measured by high

percentages of correct responses.

Team Communication

The presentation continued with a discussion

about communication that began with examples

of positive and negative verbal and nonverbal

communication. Audience members discussed

how various styles of communication affect

their willingness to engage in the activities

around them. If someone is on the receiving

end of negative verbal or nonverbal communi-

cation, they tend to separate themselves from

the situation and could miss opportunities to

provide better patient care or not have situa-

tional awareness of events that are happening.

Situational barriers (eg, hierarchy) and behav-

ioral barriers (eg, emotions, culture) to good

communication were discussed, as were tech-

niques needed for good communication, such as

 eye contact,

 active listening,

 clear leadership,

 conﬁrmation of understanding the message,

 engagement of team members, and

 healthy discussions of pertinent information.

The presenters then described situational

awareness (ie, the understanding of the current

environment and the ability to accurately antici-

pate future problems to enable effective ac-

tions).

9,10

Situational awareness requires that the

health care professional be aware of what is tak-

ing place around him or her at all times. To

achieve situational awareness, team members

must possess a shared mental model (eg, mutual

understanding of the problems, goals, and strate-

gies related to the situation in which they ﬁnd

themselves).

9,10

This awareness fosters good com-

munication, provides a context for action, helps

team members predict the behavior or needs of

other team members, and helps identify problems.

The absence of a shared mental model is a com-

mon source of conﬂict in the OR. If team mem-

bers do not share a common goal, variability in

results and misinterpretations can result.

Good team communication skills are required

to provide a culture of patient safety. The team

communication skills emphasized in the program

were the use of situation, background, assessment,

and recommendation (SBAR); callout; and check

back. The SBAR technique provides a framework

for communication between team members re-

garding the patient’s situation and condition.

The callout technique is a verbal means of con-

veying important or critical information and in-

forming all team members of the information si-

multaneously.

It helps team members anticipate

the next steps and change their mental model, if

needed. The check-back technique is a method of

closed-loop communication used to ensure that

information has been received and understood.

For example, the sender initiates the message and

the receiver provides feedback about the mess-

age’s receipt and its content. The sender then ver-

iﬁes that the information is correct.

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Figure 2. Ticket to the OR. Printed with permission from Lehigh Valley Health Network Cedar Crest,

Allentown, PA.

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Transfers of responsibility and accountability

from one person to another or from one team to

another were then discussed.

At LVHN, hand-

off communication in the OR is facilitated by the

“Ticket to the OR” (Figure 2). The ticket is a

document that helps ensure proper patient transfer

to the OR suite and is used by staff members in

the area sending the patient to the OR, the person

transporting the patient to the OR, the holding

room staff members, and the OR staff members.

Vital information is included on the ticket, and

the patient cannot be transferred from one area

to another without a completed form. The pre-

existing preoperative checklist was modiﬁed to

act more like an airline ticket as a series of

checks and balances with hard stops and a physi-

cian portion. If everything is not correct, the pa-

tient cannot move forward.

To continue the communication discussion, the

ﬁrst video vignette, ﬁlmed in the facility’s educa-

tion department using OR team members, was

presented. This vignette shows the circulating

nurse, anesthesia professional, and patient en-

gaged in a preinduction brieﬁng (Figure 3). Com-

pleting this preinduction surgical safety checklist

is the ﬁrst part of the World Health Organization

(WHO) Surgical Safety Checklist.

In a pilot

study, use of the WHO checklist was found to

increase compliance with standards and decrease

complications from surgery.

Then the video showed team members (eg,

circulating nurse, anesthesia professional, sur-

geon, scrub person) engaged in a preprocedural

brieﬁng (ie, time out) in the OR before induc-

tion of anesthesia (view Supplementary Video

at http://www.aornjournal.org). The time out is

the second element of the WHO checklist

and

is the last step to be completed before an inva-

sive procedure (Figure 4). An effective time out

must have all team members’ buy-in and atten-

tion. Each team member must actively partici-

pate, and the time out must end with a collective

Figure 2. Continued

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agreement regarding all elements of the safety

checklist before the team can continue with the

procedure. The time out offers team members

an opportunity to introduce themselves, discuss

pertinent patient factors and goals, voice con-

cerns, and conﬁrm their understanding and

agreement to the proposed plan. During the time

out, participants verify the procedure to be per-

formed, the equipment needed, and potential

intraoperative variations. Two vignettes were

shown to demonstrate the time out; the ﬁrst dem-

onstrated a poor time out in which the essential

elements were not discussed and no one was

paying attention, and the second demonstrated

Yes

Not

applicable

Patient confirms identity, surgical site, procedure, and consent

deifirev gnikram etiS

Functional anesthesia machine and medication check

performed

deifirev yrtemixo eslup lanoitcnuF

deifirev seigrella tneitaP

deifirev tnemssessa ksir yawriA

Blood products typed, crossed, and screened

Surgical equipment available and functional

Figure 3. Preinduction surgical safety checklist for the circulating nurse, anesthesia professional, and patient.

Adapted with permission from Lehigh Valley Health Network Cedar Crest, Allentown, PA.

Team members participating (Circle those present):

Anesthesia professional

Surgeon

Circulating nurse

Scrub person

Surgical assistant (2nd surgeon, certified RN first assistant)

Yes

Not

applicable

All team members have introduced themselves by name and role

Patient’s name, planned procedure, and where the incision will

be made verified

deifirev sisongaid erudecorP

Initial sponge and instrument counts performed

Instruments available and sterility verified including indicator

results

Equipment issues addressed

Comments:

deyalpsid stluser gnigami laitnessE

Figure 4. Preprocedural brieﬁng (ie, time out) surgical safety checklist before the initial incision is made.

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an active and engaged team performing the time

out correctly.

The presenters then discussed the postproce-

dural debrieﬁng (Figure 5), which is the third por-

tion of the WHO checklist.

The debrieﬁng usu-

ally occurs after the surgeon closes the incision

while the team is still in the OR. The surgeon

leads the debrieﬁng and follows the checklist to

ensure that the procedure and diagnosis, counts,

and specimen documentation are correct. Discus-

sions continue regarding improvements and ele-

ments that need to be communicated to postanes-

thesia care unit or intensive care unit personnel.

Pitfalls to an effective debrieﬁng include lack of

engaged participation, laying blame, and saving

information for gossiping after the procedure.

The presentation of effective communication

continued with a discussion about conﬂict and

conﬂict resolution. Conﬂict occurs when people

work together in the OR. Team members need to

expect conﬂict and view it as an opportunity to

disagree in a respectful manner. Common ap-

proaches to conﬂict resolution are accommoda-

tion, compromise, avoidance, dominance, and tri-

angulation.

If these approaches fail to resolve

the issue, conﬂicts can be resolved by using the

describe, express, suggest, or consequences (DESC)

approach.

The DESC approach asks the partici-

pant to

 describe the speciﬁc situation,

 express his or her concerns about the action,

 suggest other alternatives, and

 state the consequences.

Using this method, team members can reach a

consensus about how to resolve the conﬂict.

Participants were provided with three assertion

techniques to help them speak up when necessary:

 the CUS (ie, concerned, uncomfortable, stop)

approach,

 the two-challenge rule, and

 the “stop the line” technique.

In the CUS approach, a team member states,

“I am concerned.” If the situation escalates, the

Team members participating (Circle those present):

Anesthesia professional

Surgeon

Circulating nurse

Scrub person

Surgical assistant (2nd surgeon, certified RN first assistant)

Yes

Not

applicable

Procedure performed

Postoperative diagnosis verified

Final sponge and instrument counts correct

Specimen labels and disposition verified out loud

Wound classification verified

Performance improvement issues addressed

Comments:

Postanesthesia care unit recovery issues addressed

Comments:

Figure 5. Postprocedural debrieﬁng surgical safety checklist completed before the patient leaves the OR.

Adapted with permission from Lehigh Valley Health Network Cedar Crest, Allentown, PA.

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team member states, “I am uncomfortable.” If the

safety threat continues, the team member says,

“Stop, there is a safety issue.”

The ﬁrst two as-

sertions (ie, I am concerned, I am uncomfortable)

are also known as the two-challenge rule,

and

the third assertion (ie, stop, there is a safety issue)

is the “stop the line” technique. “Stop the line” is

a phrase coined in the automobile industry that

allows any member of the team to stop the pro-

duction line if he or she sees a defect.

For

patient safety, “stop the line” would be used if

a team member believes that safety had been

breached, time is needed to conﬁrm vital informa-

tion, or there is a sense that the patient is in dan-

ger. Any team member should feel empowered,

comfortable, and safe to stop the line.

If the

team member does not feel comfortable or the

team does not stop, the supervisor is notiﬁed

immediately.

EVALUATION PHASE

During a six-month period, the course was pre-

sented to nearly all intended participants (Table

1). All participants received a postcourse survey

and evaluation, which must be completed to re-

ceive credit for the course. According to the eval-

uations, after taking the course, 78% of partici-

pants believed that they were better able to

question decisions or actions of those with more

authority. In addition, 75% stated that they were

no longer afraid to ask questions when something

did not seem right.

The team also wanted to assess the beneﬁt of

the various teaching tools used throughout the

training course. Based on free-text responses,

25% thought the communication tools were most

useful, 21% thought the videos were most useful,

and 14% thought that review of the importance

of safety and having OR processes in place were

most useful.

Positive response to the course was not the

only success. During the year before implemen-

tation of the course, perioperative services per-

sonnel had examined 12 RCAs, including near

misses and sentinel events. Since the mandatory

safety presentations were conducted, there has

been a marked decrease in the number of inci-

dents that require an RCA. During the ﬁscal year

after the presentations (ie, July 2010 to June

2011), only four RCAs were required in the peri-

operative services division.

FOLLOW-UP PHASE

As a result of the overwhelmingly positive results

from the course, quarterly education sessions have

been added to accommodate the arrival of new

staff members. An online version of the course

has been posted to the facility’s internal learning

management system and is accessible to all staff

members. Members of the OB/GYN department

have adopted the course for use with their divi-

sion. The team also presented the course to a

hospital in Tampa, Florida. The team plans to

reconvene and create a second course on other

pertinent safety topics.

CONCLUSION

The perioperative team training safety course of-

fered participants key tools to enhance communi-

cation in the perioperative environment. By using

a variety of teaching techniques, team members

taught audience participants the importance of

communication, as well as situations in which

to apply improved communication techniques.

Collaboration between several departments in the

hospital was fostered. The course also promoted

TABLE 1. Demographics of Course

Participants (N ⴝ 809)

Surgeons 216

Anesthesia care providers 30

Obstetricians and gynecologists 43

Obstetrician and gynecology residents 18

Surgical residents 36

Advanced practice clinicians 82

Certiﬁed RN anesthetists 108

OR staff members (eg, RNs, surgical technologists) 235

Others (eg, ancillary staff members) 41

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transparency of real issues. By involving all the

departments, staff members could better under-

stand the challenges and work to implement per-

manent solutions.

SUPPLEMENTARY DATA

The supplementary video associated with this

article can be found in the online version at

doi: 10.1016/j.aom.2012.03.002.

Editor’s note: Magnet is a registered trademark

of the American Nurses Credentialing Center,

Silver Spring, MD. TeamSTEPPS is a registered

trademark of the Agency for Healthcare Research

and Quality, Rockville, MD.

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Hope L. Johnson, MSN, RN, CNOR, is the

director of operative services at Lehigh Valley

Health Network Cedar Crest in Allentown, PA.

Ms Johnson has no declared afﬁliation that

could be perceived as posing a potential con-

ﬂict of interest in the publication of this article.

Diane Kimsey, MS, RN, CNOR, is the direc-

tor of perioperative services at Lehigh Valley

Health Network Muhlenberg in Bethlehem, PA.

Ms Kimsey has no declared afﬁliation that

could be perceived as posing a potential con-

ﬂict of interest in the publication of this article.

PATIENT SAFETY: BREAK THE SILENCE

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