Overall the results show a lack of organisational safety culture development. Only 63% of the respondents stated that verifying the correct patient, site, and procedure is a joint team responsibility. Routines for ensuring the correct patient, correct site, and correct surgical procedure were practised significant differently (P < 0.001) amongst our medical professionals (Table 2). Figure 3 presents the differences between these professionals in ensuring patient identity prior to every surgery. Nurse anaesthetists are the gatekeepers of correct patient identity in our COU, and thus are more responsible than other team members for verifying patient identity during transfer to the operating room. Hence, the other surgical team members seemed to rely on the locally established system about whether to accept or eventually reveal incorrect patient situations in the operating room. We regard this as an unsatisfactory safety assurance system. In our view, all involved medical personnel must check patient identity with regard to their own medical objectives. To address team responsibility for verifying the correct patient and identity we strongly recommend routinely use of a surgical safety checklist [7, 10].
In the present study, survey comments of surgical team members underline that various flaws in the operation planning system or incorrect information ahead of surgery contributed to the extensive experience of miscommunication. This finding corresponds with a concurrent safety climate study in our hospital that found surgical patient information handover between departments or units to be poor . Other studies underline the importance of communication [3, 11, 12]. Safety attitudes in an organisation should be monitored through safety climate questionnaires and interviews of staff as part of a systematic program aiming to improve safety.
Thirty-eight per cent of the participants experienced instances of unconfirmed patient identity in the operating room, and 19% experienced wrong patients being brought into the operating room. The number of surgical team members experiencing incorrect surgeries (i.e., wrong patient brought into the operating room, surgery performed on the wrong site, or the wrong procedure planned) seems high. According to our results, these experiences are expected to occur at least once during one’s professional career. In a study of wrong-site surgeries reported to the Pennsylvania Patient Safety Reporting System, Clarke et al. found that of 433,528 reports, 427 notifications were about wrong-site surgery. Of these, 70% were wrong side, 56% were near misses, 14% were wrong location/level, 9% were wrong procedure, and 8% were actually performed on the wrong patient .
Experiences of surgery planned for the wrong site/side (81%) and wrong positioning of the patient on the operating table (43%) revealed that near misses were familiar to most of the surgical team members in our study. Incidents of near misses are prone to occur up to 300 times more often than actual events . A literature review underlines the advantages of reporting near misses as they are more frequent than adverse events and with fewer barriers to reporting . A study of wrong-site surgery reported that 16% (173/1050) of the surgeons were about to operate on the wrong site but were warned prior to incision, and 21% (217/1050) reported that they had performed wrong-site surgery at least once .
Our study did not examine the actual incidence of incorrect surgeries. However, from our results we could infer that wrong site/side near misses would probably mitigate by systematic site marking prior to surgery. Marking the site or side before surgery is one of the recommendations of the JC to prevent incorrect surgery . This includes preoperative routines for when site marking should be performed, how the site should be marked, and by whom. Marking the wrong site or patient may occur in scenarios in which surgeons rush to the operating room to mark sites that failed to be marked in the preoperative ward. Multiple surgeons performing several procedures on the same patient and unusual time pressures are amongst the factors contributing to wrong-site surgery .
The near misses identified in the present study highlight the need for implementing systematic safety efforts in surgical care. Using checklists that cover the entire surgical pathway, from admission to discharge, as described in the SURPASS comprehensive checklist system, can further improve surgical care and prevent incorrect surgery .
Of the surgical team respondents, 60% experienced planning the wrong procedure. The answers to the open-ended question of our survey revealed various reasons. A common reason was insufficient communication between the surgeons and the operating room nurses or anaesthetic staff due to lack of information in the electronic planning system or lack of information from the surgeon.
According to previous reports, performing a wrong procedure is not the most frequent adverse event . However, our study suggests that preoperative planning and communication in our hospital can be improved. The National Patient Safety Agency reported that implementing the WHO safety surgical checklist could reduce incorrect surgeries [12, 23]. Panesar et al. found that checklists could potentially mitigate 14.9% of near misses and 83.3% of harmful events [12, 23]. In another study of surgical checklists, the procedure check during the Time Out was rated as ‘very important’ by nurses and ‘important to some degree’ by surgeons, indicating that different professionals perceive checklists differently .
Attitudes towards protocols
Incorrect surgery occurs in the context of an organisation, teams, and culture. As 91% of the surgical team members in the present study had a positive attitude towards time-outs, the majority of professionals and groups welcomed a Time Out protocol in the operating room. Perceptions are prone to be influenced by the awareness evoked in the near-miss survey and by its results. Hence, these positive attitudes towards protocols seem to have paved the way for the subsequent, successful implementation of the WHO’s Surgical Safety Checklist in our hospital. Indeed, compliance to the three parts of the checklist was 77% to 85% . Moreover, in the checklist-intervention group, there was a reduction in frequency of near misses reported, suggesting that the checklist had mitigated, to some degree, the problem of operating room mistakes .
An important finding of the present study is that raised awareness amongst the clinical staff about near misses in daily routines and safety barriers might have positive influence prior to checklist implementation. High checklist compliance may be challenging to maintain over time. In our hospital, adjusted team involvement was observed in a qualitative study of nurses’ experiences with the use of the Surgical Safety Checklist after one year . Three strategies were identified amongst operating room nurses and nurse anaesthetists—distancing, moderating, and engaging; all influenced checklist performance and compliance .
Eliminating medical errors
The high trust patients have in hospital staff mandates that we strive to achieve a zero-level of preventable incorrect surgery. Modern surgical activity could be compared to high reliability organisations (HROs). HROs are complex: They perform tasks under time pressures, with demanding activities and low incident rates or with complete absence of catastrophic failures over time . However in hospitals, adverse events occur in nearly 1-in-10 in-hospital patients . In HROs the system approach is primed at all levels of the organisation, with a preoccupation of the possibility of failure and with continual training on familiar scenarios .
A systematic review and a study of extended Surgical Time Out do not support the effectiveness of the current JC Universal Protocol in decreasing the incidence of wrong-site or wrong-level surgery [11, 27]. Hence, incorrect surgery may be prevented by surface body marking of the targeted anatomical structure and by displaying these images on monitors in the operating room . Additionally, intraoperative imaging by fluoroscopy and ultrasound may also confirm the diagnosis and severity in a variety of clinical situations. In cardiac surgery, trans-oesophageal echocardiography is frequently used to define the current clinical problem and may be of crucial importance in deciding the final surgical strategy.
Recently, Beuzekom and colleagues performed a controlled pre-post intervention study to minimise latent safety risk factors in the operating room and found lower perceived and reported incident rates in the intervention group . In the study of Pronovost et al., eliminating medical errors and maintaining a low incident rate after implementing a checklist and infection control procedures to prevent bloodstream infections related to catheter insertions indicate acceptance of an improved standard of care . Building clinical safety defences and barriers (i.e., intraoperative imaging, ultrasound and checklists) in operating rooms applies to a systematic approach for enhancing and supporting surgical team members in minimising near misses and errors [13, 25].
Systematic risk reducing efforts
To prevent near misses and incorrect surgery we suggest implementing:
Hospital safety improvement programs
Monitor and develop safety culture
Chairs must report on an support safety efforts
Build in clinical safety defences and barriers
Surgical team training
The reports in the survey of surgical team members’ experiences of incorrect surgery are probably referring to the same occasions and cases. This could be regarded as a limitation; however, the aim of this study was not to count the numbers of actual incorrect surgeries. Since non-responder analysis was not performed, we have little information about personnel who failed to respond to our survey. Nonetheless, the response rate of 64% is quite satisfactory for an email-based survey. The questionnaire depended on surgical team members’ memory of incorrect surgery experiences at this hospital. This could have biased the accuracy of the responses. Furthermore, an observation of intraoperative routines could have added more in-depth understanding of near-miss experiences in the operating rooms.