By Don Sadler

It has been nearly 20 years since the publication of “To Err is Human: Building a Safer Health System,” a report prepared by the Institute of Medicine. The report revealed that as many as 98,000 hospital patients die in the U.S. each year as a result of medical errors.

Since the report was published in 1999, subsequent studies have estimated that patient hospital deaths could actually be four times higher than this.

Emphasis on Improving Communication

Eye-opening statistics like these have prompted the health care industry to place greater emphasis on improving team communication in order to limit medical errors that lead to patient deaths.

With this in mind, the Association of periOperative Registered Nurses (AORN) recently published the “Guideline for Team Communication.”

According to AORN Perioperative Practice Specialist Mary C. Fearon, MSN, RN, CNOR, the lead author of the guideline, this is the first evidence-based guideline to address the importance of communication in the perioperative environment.

In addition to new content, Fearon says the guideline includes information from the AORN position statement on the prevention of wrong site, wrong patient and wrong procedure surgeries. It also includes the “Guideline on Transfer of Patient Care Information.”

“We received more than 500 comments on the guideline during the public comment period, including comments from other professional organizations,” says Fearon.

For example, the American College of Surgeons noted:

“Overall, the guideline is well written and thorough. It matches the current safety culture we and many others are implementing, recognizing that communication breaks are a key and common issue when safety and quality issues arise.”

Fearon says that most adverse events in the health care setting are caused by human error.

“The research demonstrates that when health care organizations put standardized communication processes in place, the occurrence of human error is decreased,” she says.

“When a perioperative team is working together with a shared mental model, they are more resilient and can more effectively minimize the risk of human errors,” she adds.

Creating a Safety Culture

Most perioperative team members would probably say that their team communicates well. But Fearon believes that all perioperative teams can improve their communication.

“Many institutions are utilizing tools such as TeamSTEPPS and Crew Resource Management to help incorporate a safety culture within the perioperative environment,” she says.

The AORN “Guideline for Team Communication” provides instructions for improving perioperative team communication through a culture of safety that incorporates the following:

  • Team training
  • Simulation training
  • Standardized transfer of patient information (e.g., hand overs or hand offs)
  • Briefings and debriefings
  • Timeouts
  • Surgical safety checklists

According to Fearon, the collective evidence demonstrates that communication breakdowns in the perioperative setting are a factor in events that adversely affect patients.

For example, 70 percent of adverse events in the surgical environment are caused by breakdowns in communication among health care providers.

“The perioperative environment is stressful and perioperative team members are under increasing pressure from numerous demands and complex functions that lend themselves to error,” says Fearon.

Despite these pressures, though, patient safety must remain a top priority for perioperative nurses and cannot be sacrificed for efficiency.

“Communication tools and team training programs provide a foundation to improve the chances that communication is conveyed effectively and received accurately,” says Fearon.

Specifically, she notes that the surgical safety checklist is an effective tool for improving communication in the perioperative environment.

“The guideline provides tools such as checklists and briefing and debriefing processes to assist facilities in designing tools that work in their specific setting and address their individual needs to overcome obstacles to effective communication,” says Fearon.

Importance of Simulation Training

Fearon believes that simulation training on the use of tools like checklists will enhance communication practices in any facility.

“Allowing the perioperative team to develop the checklists based on their environment and type of practice or surgical specialty strengthens the value of any communication tool,” she says. “Otherwise, the briefings and debriefings are run by rote and the risk for mistakes increases.”

In fact, AORN recommends a stronger focus on briefings and debriefings.

“Performing a highly engaged briefing with the entire team prior to the patient entering the operating room allows the team to gain valuable knowledge from each professional,” says Fearon. “It also leads to a shared mental model or shared focus on the plan of care for each patient.”

Briefings and debriefings can also prevent potential distractions and delays during the procedure.

“A quality debriefing provides safety checks for prevention of retained surgical items by announcing the status of the count,” says Fearon. “It also improves specimen identification and disposition by confirming what was stated during the procedure.”

“An effective debriefing gives the perioperative team an additional review to improve care and outcomes for future patients,” Fearon adds.

Health care organizations should also promote respect among team members by encouraging honesty and collaborative practice and making sure team members are comfortable speaking up.

Other ways to promote team member respect include fostering learning, holding team members accountable for their behavior, providing opportunities for shared decision making at all levels, and recognizing the value of each team member’s contributions.

Takeaways from the Guideline

AORN has identified a number of key takeaways from the “Guideline for Team Communication.” These include the following:

  • Health care organizations should establish administrative processes to create a patient safety culture and encourage team members to actively engage in the culture.

“Perioperative team leaders can promote safety by discouraging disruptive behavior by team members and encouraging behaviors that promote reporting of safety concerns,” says Fearon.

  • Health care organizations should establish an interdisciplinary team with authority and responsibility to provide oversight for the patient safety culture.

This team should include nurses, support personnel, surgeons, anesthesia professionals, perioperative services executives, quality management personnel and risk management personnel.

  • Health care organizations should establish and implement a standardized briefing process before the surgical procedure.

The interdisciplinary team should create the briefing process with input from perioperative team members representing individual service lines.

  • Standardized safe surgery checklists should be used during a timeout and adapted to the patient population served.

Fearon notes that standardized safe surgery checklists have been associated with fewer complications, improved communication, improvement in facility safety culture and increased detection of potential safety issues.

  • A health care organization’s quality management program should evaluate and monitor team communication and the culture of safety.

In addition, dashboards of patient safety indicators should be developed to provide personnel with visual information on progress in improving safety and sustaining safety measures.

Perioperative team training should include simulation training with all perioperative team members.

“Providing team training in a simulation environment allows the team to improve communication and fosters team building in a non-stressful environment,” says Fearon.

Obtaining the Guideline

The AORN “Guideline for Team Communication” became effective on January 15, 2018. For information or to purchase the guideline, visit https://www.aorn.org/guidelines.