Lessons From Flight Crews Can Help Surgical Teams Work Better

Surgical death rates might be reduced if operating room staff borrowed team-building procedures used by the airline industry, a new study suggests.

A program that trained operating room workers to talk about potential challenges before surgeries, to use checklists and to review what went right or wrong after surgeries significantly reduced the surgical death rate at participating hospitals, the study says.

In the study, researchers analyzed data on more than 182,000 patients who had undergone surgery at 108 Veterans Health Administration hospitals between 2006 and 2008. Of those hospitals, 74 had implemented the Medical Team Training program, using error-reducing techniques borrowed from the aviation industry and NASA (National Aeronautics and Space Administration).

After one year, deaths at facilities that had implemented the training program fell by 18 percent, compared to 7 percent at hospitals that had not yet gone through the training.

The decline in the annual surgical mortality rate was almost 50 percent greater at trained hospitals than un-trained hospitals, the team noted.

"The ultimate goal is to have good teamwork and communication to reduce adverse events," said senior study author Dr. James Bagian, a former astronaut who is now the chief patient safety and systems innovation officer for the University of Michigan Health System. "This study shows we had some success. The longer the facility did the program, the greater the improvement in mortality."

The study is in the Oct. 20 issue of the Journal of the American Medical Association.

Surgical errors remain a major concern in American hospitals. In fact, a study published Monday in the Archives of Surgery found that egregious and devastating errors - operating on the wrong patient or the wrong body site - still occur. Many of the mistakes cited in that report occurred due to simple errors in judgment or because surgical teams had failed to perform standard pre-operation checks.

The Michigan study focused on a training program that includes two months of planning and preparation with each hospital's surgical staff and a day-long instruction session. At the time of its implementation, Bagian was chief patient safety officer for the Veterans Health Administration's National Center for Patient Safety.

The training emphasizes the importance of teamwork and effective communications; encourages surgeons, anesthesiologists, nurses and technicians to challenge one another if they notice safety lapses; and encourages the use of checklists to guide discussions that include preoperative briefings and postoperative debriefings.

Like NASA, operating rooms tend to be hierarchical, with the surgeon at the top. This structure means other operation room staff are sometimes hesitant to speak up, Bagian said.

"When you look at problems and adverse events in health care, most of them have as one of their major causative factors a failure of communication," Bagian said. "Based on my background in aviation and NASA, it always was stunning to me that in health care we were very casual and not rigorous in the way we communicated."

According to Bagian, prior research has also shown that physicians tend to rate themselves as good communicators, even though the rest of the OR staff doesn't necessarily agree.

Lots of workers can relate, no doubt. "The bosses think communication is great, people down the line think it's not as good," Bagian said.

To alleviate that type of disconnect, Bagian recommends briefings and debriefings, in which operating room staff get together for a few moments before a surgery to discuss concerns, anticipate challenges, and make sure they have the right tools and supplies.

Post-op debriefings were a learning tool that helped operating room staff avoid future errors, he said.

The briefings can be done quickly, and the study found procedures actually took less time after implementation of the program, Bagian said.

Dr. Peter Pronovost, a professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine who wrote an accompanying editorial, said the study provides strong evidence that teaching operating room staff about teamwork and effective communication can reduce deaths among surgical patients.

"Medicine has for so long emphasized technical work over team work. We focus on putting tubes in the right places, or tying knots so that wounds don't fall apart," Pronovost said.

"We needed to do that but we have relatively under-invested in teamwork skills," he added. "Poor communication leads to a significant amount of preventable harm, and this study provides a practical way to address some of the teamwork challenges."

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