A systematic quantitative assessment of risks associated with poor communication in surgical care

TY - JOUR

T1 - A systematic quantitative assessment of risks associated with poor communication in surgical care

AU - Nagpal, Kamal

AU - Vats, Amit

AU - Ahmed, Kamran

AU - Smith, Andrea B

AU - Sevdalis, Nick

AU - Jonannsson, Helgi

AU - Vincent, Charles

AU - Moorthy, Krishna

PY - 2010/6

Y1 - 2010/6

N2 - HYPOTHESIS: Health care failure mode and effect analysis identifies critical processes prone to information transfer and communication failures and suggests interventions to improve these failures.DESIGN: Failure mode and effect analysis.SETTING: Academic research.PARTICIPANTS: A multidisciplinary team consisting of surgeons, anesthetists, nurses, and a psychologist involved in various phases of surgical care was assembled.MAIN OUTCOME MEASURES: A flowchart of the whole process was developed. Potential failure modes were identified and evaluated using a hazard matrix score. Recommendations were determined for certain critical failure modes using a decision tree.RESULTS: The process of surgical care was divided into the following 4 main phases: preoperative assessment and optimization, preprocedural teamwork, postoperative handover, and daily ward care. Most failure modes were identified in the preoperative assessment and optimization phase. Forty-one of 132 failures were classified as critical, 26 of which were sufficiently covered by current protocols. Recommendations were made for the remaining 15 failure modes.CONCLUSIONS: Modified health care failure mode and effect analysis proved to be a practical approach and has been well received by clinicians. Systematic analysis by a multidisciplinary team is a useful method for detecting failure modes.

AB - HYPOTHESIS: Health care failure mode and effect analysis identifies critical processes prone to information transfer and communication failures and suggests interventions to improve these failures.DESIGN: Failure mode and effect analysis.SETTING: Academic research.PARTICIPANTS: A multidisciplinary team consisting of surgeons, anesthetists, nurses, and a psychologist involved in various phases of surgical care was assembled.MAIN OUTCOME MEASURES: A flowchart of the whole process was developed. Potential failure modes were identified and evaluated using a hazard matrix score. Recommendations were determined for certain critical failure modes using a decision tree.RESULTS: The process of surgical care was divided into the following 4 main phases: preoperative assessment and optimization, preprocedural teamwork, postoperative handover, and daily ward care. Most failure modes were identified in the preoperative assessment and optimization phase. Forty-one of 132 failures were classified as critical, 26 of which were sufficiently covered by current protocols. Recommendations were made for the remaining 15 failure modes.CONCLUSIONS: Modified health care failure mode and effect analysis proved to be a practical approach and has been well received by clinicians. Systematic analysis by a multidisciplinary team is a useful method for detecting failure modes.

KW - Continuity of Patient Care/standards

KW - Evaluation Studies as Topic

KW - Female

KW - Humans

KW - Interdisciplinary Communication

KW - Interprofessional Relations

KW - Male

KW - Medical Errors/prevention & control

KW - Patient Care Team/organization & administration

KW - Postoperative Care/standards

KW - Preoperative Care/standards

KW - Risk Assessment

KW - Safety Management

KW - Surgery Department, Hospital

KW - Surgical Procedures, Operative/adverse effects

KW - Systems Analysis

KW - Total Quality Management

KW - Treatment Outcome

U2 - 10.1001/archsurg.2010.105

DO - 10.1001/archsurg.2010.105

M3 - Article

C2 - 20566980

SN - 0004-0010

VL - 145

SP - 582

EP - 588

JO - Archives of Surgery

JF - Archives of Surgery

IS - 6

ER -