Jt Comm J Qual Patient Saf. 2024 Sep;50(9):678-683. doi: 10.1016/j.jcjq.2024.04.012. Epub 2024 May 1.
Communication failures contribute to quality gaps and may lead to serious safety events (SSEs) in the operating room (OR). Our perioperative services team experienced an increased rate of SSEs in 2020. Event analysis revealed clustered causes: communication failures and lack of timely information to prepare for cases. Consequently, the team implemented a daily morning OR safety huddle conducted before bringing patients into the OR to reduce quality gaps and improve communication.
The attending surgeon and anesthesiologist, circulating nurse, and scrub staff are required to be present. Cases are discussed using a standard format designed by the OR team with built-in time for questions and clarifications. The surgeon initiates the huddle; the circulating nurse leads and records the discussion. OR leadership initially performed daily audits but gradually reduced them when huddles became standard operating procedure (SOP). SSEs were recorded from December 2015 to September 2020 preintervention and October 2020 to July 2023 postintervention.
Following the implementation of huddles, there were no SSEs for more than 900 days (2.0 SSEs/year preintervention vs. 0.0 SSEs/year postintervention). The first SSE during the postintervention period occurred in March 2023. Huddle compliance was consistently > 95%. No delays were observed in first-case on-time starts postintervention. The huddle is now SOP for all general OR teams and interventional radiology.
Implementing the morning safety huddle contributed to a reduction in the rate of SSEs without introducing delays to first-case start-times.
沟通失败会导致质量差距，并可能导致手术室（OR）发生严重安全事件（SSE）。我们的围手术期服务团队在 2020 年经历了 SSE 发生率的增加。事件分析显示出集中的原因：沟通失败和缺乏及时的信息来为病例做准备。因此，该团队实施了每日早晨的 OR 安全围堵，在将患者带入 OR 之前进行，以减少质量差距并改善沟通。
要求主治外科医生和麻醉师、巡回护士和洗手护士到场。使用 OR 团队设计的标准格式讨论病例，并内置提问和澄清时间。外科医生启动围堵；巡回护士领导并记录讨论。OR 领导层最初进行每日审核，但当围堵成为标准操作程序（SOP）时逐渐减少。从 2015 年 12 月到 2020 年 9 月进行干预前记录 SSEs，从 2020 年 10 月到 2023 年 7 月进行干预后记录。
实施围堵后，超过 900 天没有发生 SSE（干预前每年 2.0 次 SSEs，干预后每年 0.0 次 SSEs）。在干预后的第一个 SSE 发生在 2023 年 3 月。围堵合规性始终>95%。干预后第一例准时开始没有观察到延迟。围堵现在是所有普通 OR 团队和介入放射学的 SOP。
实施早晨安全围堵有助于降低 SSE 发生率，而不会延迟第一例开始时间。
