"The surgeon is supposed to be the captain of the ship, right?" asks Martin A. Makary, MD, MPH, the director of the Johns Hopkins Center for Surgical Outcomes Research and noted champion of teamwork in the operating room. "But how can you be the captain of the ship when you don't even know who's on the ship?"

This is why, in the moments before each of his cases, Dr. Makary and all team members introduce themselves both by name and by their role on the surgical team. "I'm Dr. Makary and I'm the attending surgeon on the case ???"

"We go around the whole room and do this," he says. "Before every case."

Next, he, the anesthesia provider and the circulating nurse verbally confirm the patient, the site and the procedure. "Does everyone agree that this is Patient X, who is having a hernia repaired?"

It's all part of following the World Health Organization's Surgical Safety Checklist, which Dr. Makary helped develop. A standardized OR briefing program became Hopkins policy in June 2006. Before the new policy was implemented, many surgeons would walk into the OR and start working without a conversation of any kind and without even knowing the names of the nurses and other staff who were assisting them, says Dr. Makary.

The checklist, which we introduced you to last month (see "Surgical Safety? Check!" on page 19 of November's issue), presumes two things:

• that wrong-site, wrong-procedure and wrong-patient operations often occur because of failures in communication and collaboration; and
• that there's precious little discussion and planning before skin incisions.

"Research has shown that people feel more comfortable speaking up when there's a formal introduction and when you go over details of the case beforehand," says Dr. Makary.

OR briefings
You've heard of the surgical time out, a pause immediately before incision during which you identify and verify the patient, surgical site, procedure and position at hand. Now comes the two-minute briefing, a meeting during which all members of the OR team state their name and role while the lead surgeon identifies and verifies the critical components of the operation.

The briefing identifies three phases of an operation, each corresponding to a specific period in the normal flow of work: before the induction of anesthesia ("sign in"), before the incision of the skin ("time out") and before the patient leaves the OR ("sign out"). In each phase, a checklist coordinator must confirm that the surgery team has completed the listed tasks before it proceeds with the operation.

Dr. Makary estimates it takes two minutes to complete the OR briefing, which occurs after anesthesia is achieved and before the incision, and includes three critical components:

• each member of the OR team states his or her name and role;
• the surgeon leads the time out, as required by the Joint Commission to identify critical components of the operation, including surgical site; and
• the care teams discuss and mitigate such potential safety concerns as allergies, difficult airway and risk of blood loss.

Dr. Makary predicts that you'll find checklists hanging off more and more OR tables and intravenous poles because they not only minimize errors but they also improve teamwork.

"Operating room briefings decrease the number of unnecessary delays during the operation," he says. "That's because people anticipate the needs of the surgeon better when they go over the operation's details beforehand."

Validated by study
A study by Dr. Makary and colleagues, "Operating Room Briefings and Wrong-Site Surgery," published last month in the Journal of the American College of Surgeons, validated the common-sense idea of ticking off a checklist as not only a safety tool but an efficiency booster as well. The study found that the use of a checklist goes beyond preventing wrong-site surgeries and ensuring antibiotic prophylaxis. So-called pre-operative briefings also reduced unexpected delays in the OR by 31 percent and decreased the frequency of communication breakdowns that lead to delays, says the study.

"Our research indicates that OR personnel see presurgical briefings as a useful tool to help prevent communication breakdowns," says Dr. Makary.

Although the Joint Commission and others have identified communication breakdowns as the most common root cause of wrong-site surgeries, it was not known which preventive strategies were worth following. The aim of Dr. Makary's study was to measure the association between OR briefings and clinicians' perceptions both of collaboration and of the risk factors for wrong-site surgery. Dr. Makary's study shows that most caregivers agreed that a pre-operative discussion just before skin incision to briefly review the names and roles of all team members, the operative plan, the familiarity with the procedure and potential issues for the patient increased their awareness of the surgical site and side being operated on.

"OR briefings significantly reduce perceived risk for wrong-site surgery and improve perceived collaboration among OR personnel," reports the study.

Before and after
The study found that a greater percentage of its participants agreed with each of these statements after they had experienced OR briefings than before:

• A pre-operative discussion increased my awareness of the surgical site and side being operated on.
• The surgical site of the operation was clear to me before the incision.
• A team discussion before a surgical procedure is important for patient safety (responses were similarly favorable both pre-and post-intervention).
• Team discussions are common in the ORs here.
• Decision-making used input from relevant personnel.
• Surgery and anesthesia worked together as a well-coordinated team.

"In this study, we found evidence that using OR briefings significantly reduces uncertainty about the location of the surgical site among OR caregivers," the researchers conclude. "In addition, we found OR briefings to be an effective tool in promoting teamwork between anesthesia and surgery staff members and in more fully using input from relevant caregivers for decision-making in the OR."