The influence of aviation practices on healthcare and patient safety cannot be ignored, whether it be through development of novel surgical safety checklists, skills simulators, and team training. Studies such as those carried out by Gore and colleagues demonstrate the impact of aviation personnel have had on helping to improve the perioperative communication climate and the development of aviation-based perioperative briefings . Indeed, the analogy between aviation and surgery is certainly not new, and several initiatives have evolved to improve perioperative communication and reduce surgical errors [5, 13]. These include the implementation of a standardized surgical “time-out” to ensure correct patient identity and correct surgical site, introduction of medical team training programs and of structured perioperative briefings and surgical checklists [9, 12, 14–16]. Impressively, the simple use of perioperative briefings has been shown to significantly reduce the incidence of wrong-site surgery .
In addition to the landmark WHO Surgical Safety Checklist, the Universal Protocol, endorsed by the Joint Commission, has also played an important role in addressing errors contributing to wrong-site procedures and wrong-patient surgery [9, 14]. Medical errors continue to receive increasingly widespread attention, fueled in part by the intermittent and troubling occurrence of highly publicized tragic outcomes ostensibly due to communication errors [18, 19]. Leading national organizations have thus exhorted health care providers to adopt systems – engineering approaches – that have irrefutably improved safety in other high-risk industries, such as professional aviation and nuclear power technology [4, 20].
In a recent study, we reported that despite its wide-scale implementation, the Universal Protocol has failed to eliminate the “never events” of wrong site and wrong patient errors . In a review of nearly 150 wrong-patient and wrong-site procedures, we found that 100 % of errors resulting in wrong-patient procedures, and nearly 50 % of wrong-site procedures, were the result of a communication breakdown . Based on these disturbing findings, we made a strong case for the use of mandatory standardized readbacks, briefings/debriefings, and surgical checklists, in addition to the strict adherence to the Universal Protocol [9, 21]. In response to our study, Adelman and Chelcun noted that the WHO Surgical Safety Checklist and the concept of medical team training are important adjuncts to the Universal Protocol .
While the implementation of readbacks over the span of many decades into standard flight operations has met with great success, the demands placed on verbal communication in aviation leave much room for improvement. Within the framework of readbacks, several issues still present themselves in flight safety trend analysis. Specifically, recurring errors include: (1) incorrect readbacks by pilots and lack of correction by Air Traffic Control; (2) a correct readback followed by an incorrect action in the cockpit; and (3) a correct readback by the pilot, but an incorrect recording of the readback by the controller, leading to subsequent errors [23, 24]. As such, the aviation community has continued to push for unambiguous phraseology, the insistence of complete and accurate readbacks by pilots, and the monitoring of all readbacks by air traffic control [23, 24].
While situational differences exist between the flight deck and the operating room, there is an obvious benefit of adopting communication principles of aviation to improve patient safety in surgery [25–28]. As such, the results of this preliminary study demonstrate several important factors in developing a formal program for perioperative readback implementation. First and foremost, there appears to be a strong agreement among perioperative staff that readbacks indeed represent an important communication tool in improving perioperative safety. Staff were also overwhelmingly willing to take part in a short training course to implement readbacks seamlessly and effectively. Interestingly, however, a majority of the respondents believed that readbacks were already being used appropriately in the hospital.
Respondents believed that both the training needed to integrate readbacks as well as the potential reluctance of the surgical staff to use readbacks were minor barriers to implementation. The difficulty in implementation seems to revolve around determining what kind of communication would be appropriate given the time constraints. Broadly speaking, respondents believed that readbacks had an important role in patient handoffs, critical patient orders, counting and verifying surgical instruments, and delegating multiple perioperative tasks. While concerns that the use of readbacks may cause excessive perioperative delays are understandable, a variety of studies have demonstrated that communication safety strategies may actually prevent unexpected delays and communication failures. A previous report investigated the use of preoperative briefings, and found that the briefings were associated with a 31 % reduction in unexpected delays and a 19 % reduction in communication breakdowns leading to delays . As such, in further bolstering the communication process, readbacks may further reduce the incidence of unexpected delays.
Of interest is the statistically significant difference in the strength of agreement on the potential for readbacks to improve patient safety between residents, providers, and nursing staff. Just as important is the significant difference in the healthcare provider willingness to attend a short training module on readbacks, with the strongest support for attending a training course coming from the nursing staff. The lower strength of agreement by residents on the patient safety benefits of readbacks and the lower willingness to attend a training module on readbacks may be due to a variety of factors. The training demands placed on residents may limit their emphasis and exposure to patient safety initiatives, as compared with staff nurses, technicians, and providers. A recent study that reviewed resident engagement in quality improvement initiatives noted several barriers to participation . These barriers included academic medical centers placing a higher value on individual autonomy rather than on commitment to total quality improvement, “resistance to process standardization, and low regard for systems thinking” . The authors also noted that academic centers do not value quality improvement as an academic discipline to the same extent that laboratory or clinical research is valued in career development . As such, residents may be less inclined to commit to quality improvement initiatives.
A recent paper describing a “patient safety curriculum for medical residents” found that residents were frequently not aware of the risks associated with the procedures they carried out and were often unclear on their role in improving patient safety . Indeed, these findings further bolster the need for resident-specific educational programs and opportunities for involvement in critical patient safety initiatives. Another recent study documented that resident-attending intraoperative communication can play a valuable role in preventing adverse patient events further reinforces the importance of securing resident support in the deployment of perioperative readbacks . Moreover, previous work has raised a concerning skepticism that exists among physicians about the value of certain interventions to improve patient safety .
An assessment of the “patient safety climate” in 92 hospitals found significant differences in attitudes and perceptions of patient safety and patient safety initiatives amongst different hospital work areas and disciplines, particularly between nurses and physicians . These findings underscore the importance of developing patient safety educational modules that take into account the baseline differences in safety climate between different members of the perioperative staff. Unbridled skepticism will perniciously impede the adoption of new patient safety interventions and thus needs to be investigated and addressed .
In a landmark article, Dunn and colleagues reported the successful implementation of a “Medical Team Training Program” derived from the concept of crew resource management in professional aviation . The study outlined the program’s benefit outside of the operating room, e.g. in the settings of critical care interdisciplinary rounds, and clinical unit administrative briefings. Most importantly, the authors emphasized the importance of institutional leadership support for achieving a “critical mass” of staff attendance for training sessions and successful program implementation . Impressively, Neily and colleagues demonstrated in a more recent follow-up study that the participation in the same Medical Team Training program was associated with lower surgical mortality rates . The authors showed that – for every quarter of the training program – a reduction of 0.5 deaths per 1,000 surgical procedures was achieved .
Limitations of this preliminary study include the moderate survey return rate of 50.1 %, leading to a relatively small sample size of n = 92. The limited sample size may be one of the contributing factors to the difficulty in determining respondent trends as a function of their perioperative role. Additionally, the distribution of perioperative staff was heavily skewed towards surgical residents and attending surgeons, with fewer respondents coming from the anesthesia and nursing departments. As such, broadening the sample size to include a greater number of respondents from the latter two departments and combining data from other institutions will increase the generalizability of the results. Further enquiries may also be conducted through observing response patterns as a function of whether the respondents work at an academic or community hospital. Indeed, observing and appreciating attitudinal pattern variability would be critical in developing tailored readback programs that would be acceptable to different departments in terms of content delivery and didactics. To assure greater participation from low responding provider types, it may beneficial to approach department heads and request that they disseminate the survey to their staff and strongly encourage them to complete the survey. This may provide more incentive and be more beneficial that sending the survey to staff members from a centralized and non-affiliated research group.
In terms of improving the survey in future studies, it may be beneficial to provide more detailed scenarios to the respondent where the perceived utility of readbacks could be queried. Furthermore, in order to determine the baseline use of readbacks, respondents could be queried on 1) whether they believe that they are using readbacks appropriately, and 2) whether other perioperative staff are using readbacks appropriately. This may provide provider-specific baseline data on readback use as well as further perceptions on teamwork between perioperative staff categories.
Most importantly, developing a list of specific items and scenarios where readbacks would confer the most benefit is critical to the development of a training module. As demonstrated in the results, the difficulty in determining what is appropriate to be read back in all perioperative settings stands as one of the greatest challenges in the development and implementation of a specific curriculum. In this regard, Guise and colleagues developed a “Clinical Teamwork Scale” to evaluate clinical teamwork skills based on simulation exercises and in everyday clinical care . The ease of applicability and reliability of the scale makes it a useful prospective validation tool for evaluation of the quality of a future readback program .