Purpose of Review

Surgical flow disruptions (SFD) are deviations from the progression of a procedure which can be potentially compromising to the safety of the patient. Investigators have previously demonstrated that SFDs can increase the likelihood of error. To date, there has been no investigation into flow disruptions through the eyes of clinicians in the operating room. This study, therefore, attempted to better understand SFDs and their impact from the perspective of operating room team members.

Recent Findings

After Institutional Review Board approval, a survey was sent to operating room team members including surgeons, anesthesia providers, nurses, and surgical technologists. The survey was developed to assess the perceived frequency and consequences of SFDs, and the ability to report and perceive the efficacy of reporting to management. Among 111 survey participants, 65% reported that surgical flow disruptions happen either “several times a day” or “every procedure.” Forty percent ranked poor communication as the most frequent cause of SFDs. Ten percent reported equipment failure was the most frequent cause of SFDs. Respondents who identified as attending surgeons felt impacts on patient safety and staff burnout was the most likely consequence of SFDs. Scrub technicians and nurses felt that economic consequences were the most likely result. Forty-four percent did not feel reporting led to effective change. Thirty-five percent did not believe they could report issues without adverse consequences.

Summary

Flow disruptions represent patterns or accumulations of disruptions which may highlight weak points in surgical systems and potential causes of staff burnout and medical error. The data in the present investigation demonstrate that OR team members recognize surgical flow disruptions are an important issue and believe poor communication and equipment problems are a significant factor. Our data additionally suggest the groups surveyed do not feel safe or productive in reporting flow disruptions.

中文翻译：

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手术流程中断，具有重要临床结果意义的先导调查。

审查目的

手术流程中断（SFD）是手术过程的偏差，可能会损害患者的安全。研究人员先前已经证明，SFD可以增加出错的可能性。迄今为止，还没有关于通过手术室的临床医生的眼睛进行流量中断的调查。因此，本研究试图从手术室团队成员的角度更好地理解SFD及其影响。

最近的发现

在机构审查委员会批准之后，向手术室团队成员（包括外科医生，麻醉师，护士和外科技术人员）进行了调查。该调查旨在评估SFD的感知频率和后果，以及报告和感知向管理层报告的能力。在111位调查参与者中，有65％的人报告说手术流量中断发生在“一天几次”或“每道手术”上。40％的人认为沟通不畅是SFD的最常见原因。百分之十的设备故障是导致SFD的最常见原因。被确定为外科医生的受访者认为，SFD最有可能导致对患者安全和工作人员倦怠的影响。擦洗技术人员和护士认为最有可能造成经济后果。44％的人认为报告没有带来有效的改变。35％的人认为他们可以举报问题而不会造成不利后果。

概要

流量中断代表中断的模式或累积，可能会突出外科系统的薄弱环节以及人员倦怠和医疗错误的潜在原因。本调查中的数据表明，手术室成员认识到手术流程中断是一个重要问题，并认为沟通不畅和设备问题是一个重要因素。我们的数据还表明，接受调查的群体在报告流量中断方面并不安全或没有成效。