TALKING POINT The quality of communication in the OR impacts complication rates and surgical outcomes.

Things weren't adding up, remembers Jeanie Brown, BSN, RN, CNOR, perioperative manager at Parkwest Medical Center in Knoxville, Tenn. The consent form indicated the left knee was to be operated on, but the schedule said it was the right knee that needed repair. That's when one of her circulating nurses issued a hard stop, discussed the surgical site with the patient and called in the surgeon to resolve the laterality issue. There was no way a wrong-site surgery was happening on the nurse's watch. "Conversations about patient safety must be constant," says Ms. Brown. "If you communicate ineffectively or fail to communicate at all, you're setting patients up for harm and your colleagues up for failure."

There's a clear correlation between case outcomes and how well the surgical team discusses key safety concerns, the critical stages of surgery and the progress of the procedure, says E. Patchen Dellinger, MD, a general surgeon at the University of Washington Medical Center in Seattle.

The simple explanation of ineffective communication in the OR can be traced to the traditional staffing hierarchy in which the demanding surgeon controls the room with little to no input from the nurses and surgical techs. Research has supported this belief, says Dr. Dellinger, who adds complications are more likely to occur during cases performed by surgeons who are poor communicators.

Ask different members of your surgical team if they feel comfortable speaking up when something seems amiss in the OR. Nurses and techs rarely express the same self-assured confidence as surgeons, so it's not surprising that studies show surgeons are much more likely than the team members they work with to voice concerns about patient care, says Dr. Dellinger.

How can surgeons establish a collegial atmosphere and emphasize the importance of open communication in the OR? He suggests surgeons ask team members, Does anyone have any specific concerns about this patient and the procedure? Please speak up at any time during the procedure if you believe the well-being of the patient is being jeopardized.

A safety-focused dialogue must continue throughout the case. "The surgeon should encourage open communication by engaging nurses, techs and anesthesia providers with case updates and specific safety concerns as they arise," says Dr. Dellinger. "It's that constant back-and-worth among members of the surgical team that will maintain the dialogue established during the pre-op time out."

LEAD BY EXAMPLE Surgeons must create a working environment that fosters transparent discussions about safe patient care.

Check all the boxes
Surgical safety checklists can reduce the risk of errors in the OR, but it's not enough to adopt the World Health Organization's checklist template. You must include your surgical team on adapting the template to the specific needs of your facility. You must also train your surgeons and staff on how to use a checklist effectively. Dr. Dellinger suggests you break it down into 3 segments:

Before anesthesia induction. Include the patient in this portion of the pre-op safety check. Verify the patient's name, the surgical site, the procedure that's about to be performed and that the consent is complete and accurate. Mark the surgical site; ask patients to confirm the location and type of procedure they're scheduled to undergo.

Before the incision. Have each member of the team introduce themselves and briefly explain their role in the procedure. The surgeon should lead the entire team in confirming the patient's name, the surgical site and the surgery to be performed. The surgeon should also alert the surgical team to critical parts of the case, issues that might arise and the procedure's expected duration. Anesthesia pro-viders must bring up any concerns they have about the patient's condition, including anticipated management of difficult airways. Nurses and surgical techs are in charge of confirming the sterility and availability of needed equipment. Finally, the entire team must confirm that prophylactic antibiotics were administered within 60 minutes of the incision time.

Before the patient leaves the OR. The circulating nurse must record the surgery that was performed, confirm that all objects and instruments used during the procedure are present and accounted for, and ensure collected specimens are properly labeled. The entire team needs to discuss issues with equipment that need to be resolved and the basic plan for the patient's recovery. What's the next step in their care? Do they require any medications? How will their pain be managed? Complete the debriefing when the entire surgical team is in the room and the details of the case are still fresh. Be sure team members are able to participate in the huddle without jeopardizing patient safety.

The debriefing is invaluable to promoting patient safety, but is often skipped by busy surgical teams, who immediately move on from the just-finished case to focus on prepping the next patient for surgery, says Ms. Brown. She suggests you emphasize to your staff the importance of meeting after cases. Let them know that effective debriefings should take only a few minutes to complete and can help identify concerns that need to be resolved and ways to improve patient care moving forward. Be sure to have a method in place to record and address the concerns that staff bring up during debriefings.

Always aware
"Engage patients in friendly conversation as soon as they enter the OR," says Ms. Brown. "Introduce them to every member of the surgical team and ask about their personal lives."

The informal conversations serve the dual purpose of putting patients at ease and establishing brief but personal connections with nurses, techs and anesthesia providers, who will feel more invested in caring for the patient.

Ms. Brown's staff huddles every morning to discuss the day's schedule and safety issues that might need to be addressed. They also gather again in the early afternoon to assess how the day is progressing and to renew their focus on patient safety for the remaining cases. Both huddles keep the team focused and talking about safe patient care from the first case to the last.

Share near-misses or adverse events that occur in your facility to heighten staff's awareness of how errors can happen and to prevent complacency from creeping in. "Surgical professionals always advocate for their patients," says Ms. Brown. "But they sometimes have to be reminded about what can go wrong if they're not always thinking and talking about maintaining a safe environment." OSM