Abstract
Background Incident reports suggested that patients were reaching the operating room (OR) without completion of necessary preparatory tasks. Incidents included Near Misses with potential for harm. Parallel processing and inadequate communication among preoperative nurses, anesthesia providers, and OR nurses were determined to be root causes of many of these failures.
Objectives Significantly increase the number of days-between preoperative task-completion (PTC) failures.
Methods Incident reports were analyzed for root causes. Preoperative process flow was mapped. Process flow at other institutions was observed. Multidisciplinary bedside handoffs utilizing a task-completion checklist were tested, adapted, and adopted as a new preoperative process (figure 1). Days-between PTC failures were plotted on an XMR chart as the primary metric. First case procedure start times were plotted on XMR charts as a balancing measure. Qualitative data were collected about process issues identified by the handoff process.
Process flow chart and bedside handoff checklist
Results After introduction of bedside handoffs days-between PTC failures reaching the OR increased from every 5 days to >40 days (figure 2). The average procedure start time was delayed by 8 min (figure 3). A majority of PTC failures that were stopped from reaching the OR were surgeon-specific (figure 4A). Unavailability of nurses was a reported barrier to process success. (figure 4B).
Days-between preoperative task completion failuresIndividuals (XMR) chart depicting the days between preoperative task-completion failures that resulted in incident reports. The chart is annotated for important time points in the study. Special cause is illustrated by points/connectors in red and by points above the upper control limit. Dashed red line = upper control limit; Light blue line = Centerline depicting the mean for each value
First-case start timesIndividuals (XMR) chart depicting the average start time for first cases in the operating room. The chart is annotated for important time points in the study. Special cause is illustrated by points / connectors in red and by points above the upper control limit. The shift upward of the centerline after special cause was met in the upper chart illustrates the average start time becoming significantly later after ‘Go-Live’ of the new handoff process. The widening control limits illustrate increased variation in the start times after introducing the new process. Dashed red line = upper control limits (UCL) and lower control limits (LCL); Light blue line = centerline depicting the mean for each value
Pareto charts of issues identified by qualitative bedside handoff dataPanel A: Tasks requiring completion that were caught by bedside handoffs prior to transferring patient to the operating room. Green bars represent categories requiring surgeon presence to completePanel B: Issues that interfered with or needed completion at the time of bedside handoffs. Red bar and orange bars identify the issues with the highest count. Yellow bars represent categories related to nurse availability
Conclusions Bedside handoffs inclusive of preoperative nurses, anesthesia providers, and OR nurses increased the days between PTC incidents reaching the OR. This safety intervention had the tradeoff of a slight decrease in efficiency as measured by procedure start times. Interventions targeting nurse availability and earlier surgeon task completion are still necessary to optimize efficiency.
