Introducing standardized readbacks to improve patient safety in surgery: A prospective survey in 92 providers at a public safety-net hospital

BMC Surgery

Volumn 12, Issue , 2012, Pages

  Prabhakar, Hari ^a   Cooper, Jeffrey B ^a,b   Sabel, Allison ^c   Weckbach, Sebastian ^d   Mehler, Philip S ^d   Stahel, Philip F ^d  

^a HARVARD MEDICAL SCHOOL   (United States)

^b MASSACHUSETTS GENERAL HOSPITAL   (United States)

^c Food Science and Human Nutrition   (United States)

^d UNIVERSITY OF COLORADO SCHOOL OF MEDICINE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CHECKLIST; HEALTH PERSONNEL ATTITUDE; HUMAN; INFORMATION PROCESSING; INTERPERSONAL COMMUNICATION; MEDICAL ERROR; PATIENT SAFETY; PUBLIC HOSPITAL; QUESTIONNAIRE;

ATTITUDE OF HEALTH PERSONNEL; CHECKLIST; COMMUNICATION; DATA COLLECTION; HOSPITALS, PUBLIC; HUMANS; MEDICAL ERRORS; PATIENT SAFETY; QUESTIONNAIRES;

EID: 84862273781     PISSN: None     EISSN: 14712482     Source Type: Journal    
DOI: 10.1186/1471-2482-12-8     Document Type: Article

References (37)

1. d'Agincourt-Canning LG, Kissoon N, Singal M, Pitfield AF: Culture, communication and safety: lessons from the airline industry. Indian J Pediatr 2011, 78(6):703708.
2. Catchpole KR, Dale TJ, Hirst DG, Smith JP, Giddings TA: A multicenter trial of aviation-style training for surgical teams. J Patient Saf 2010, 6(3):180 186.
3. Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR, Rogers SO, Zinner MJ, Gawande AA: Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg 2007, 204:533540.
4. Stahel PF: Learning from aviation safety: a call for formal readbacks in surgery. Patient Saf Surg 2008, 2:21.
5. Glickson J: A view from the cockpit: surgeon and pilot Richard C. Karl, MD, FACS, promotes aviation safety in the OR. Bull Am Coll Surg 2010, 95 (11):612.
6. Hanna D, Griswold P, Leape LL, Bates DW: Communicating critical test results: safe practice recommendations. Jt Comm J Qual Patient Saf 2005, 31(2):6880.
7. Watson DS: National patient safety goals and implementation. AORN J 2009, 90(1):123127.
8. Hoover EL: Patient safety and surgeons - why the resistance? Arch Surg 2007, 142:11271128.
9. Stahel PF, Mehler PS, Clarke TJ, Varnell J: The 5th anniversary of the Universal Protocol: pitfalls and pearls revisited. Patient Saf Surg 2009, 3:14.
10. Mehler PS, Colwell CB, Stahel PF: A structured approach to improving patient safety: Lessons from a public safety-net system. Patient Saf Surg 2011, 5:32.
11. Sexton JB, Helmreich RL, Neilands TB, Rowan K, Vella K, Boyden J, Roberts PR, Thomas EJ: The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res 2006, 6:44.
12. Gore DC, Powell JM, Baer JG, Sexton KH, Richardson CJ, Marshall DR, Chinkes DL, Townsend CMJ: Crew resource management improved perception of patient safety in the operating room. Am J Med Qual 2010, 25(1):6063.
13. Karl R: Briefings, checklists, geese, and surgical safety. Ann Surg Oncol 2010, 17(1):811.
14. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, et al: A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009, 360(5):491499.
15. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Dziekan G, Herbosa T, Kibatala PL, Lapitan MC, et al: Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Qual Saf 2011, 20(1):102107.
16. Neily J, Mills PD, Young-Xu Y, Carney BT, West P, Berger DH, Mazzia LM, Paull DE, Bagian JP: Association between implementation of a medical team training program and surgical mortality. JAMA 2010, 304(15):16931700.
17. Makary MA, Mukherjee A, Sexton JB, Syin D, Goodrich E, Hartmann E, Rowen L, Behrens DC, Marohn M, Pronovost PJ: Operating room briefings and wrong-site surgery. J Am Coll Surg 2007, 204(2):236243.
18. Campion EW: A death at Duke. N Engl J Med 2003, 348(12):10831084.
19. Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ: Temporal trends in rates of patient harm resulting from medical care. Rfnet Engl J Med 2010, 363(22):21242134.
20. Hudson DW, Holzmueller CG, Pronovost PJ, Gianci SJ, Pate ZT, Wahr J, Heitmiller ES, Thompson DA, Martinez EA, Marsteller JA, et al: Toward improving patient safety through voluntary peer-to-peer assessment. Am J Med Qual 2012, 27(3):201209.
21. Stahel PF, Sabel AL, Victoroff MS, Varnell J, Lembitz A, Boyle DJ, Clarke TJ, Smith WR, Mehler PS: Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database of physician self-reported occurrences. Arch Surg 2010, 145(10):978984.
22. Adelman J, Chelcun J: Evidence-based safe surgical practices as adjuncts to the Universal Protocol. Arch Surg 2011, 146(4):489490.
23. Tiewtrakul T, Fletcher S: The challenge of regional accents for aviation English language proficiency standards: a study of difficulties in understanding in air trafiic control-pilot communications. Ergonomics 2010, 53(2):229239.
24. Taylor JL, O'Hara R, Mumenthaler MS, Rosen AC, Yesavage JA: Cognitive ability, expertise, and age differences in following air-traffic control instructions. Psychol Aging 2005, 20(1):117133.
25. O'Connor T, Papanikolaou V, Keogh I: Safe surgery, the human factors approach. Surgeon 2010, 8(2):9395.
26. Singer SJ, Rosen A, Zhao S, Ciavarelli AP, Gaba DM: Comparing safety climate in naval aviation and hospitals: implications for improving patient safety. Health Care Manage Rev 2010, 35(2):134146.
27. McCulloch P, Mishra A, Handa A, Dale T, Hirst G, Catchpole K: The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre. Qual Saf Health Care 2009, 18(2):109115.
28. Youngson GG, Flin R: Patient safety in surgery: non-technical aspects of safe surgical performance. Patient Saf Surg 2010, 4:4.
29. Nundy S, Mukherjee A, Sexton JB, Pronovost PJ, Knight A, Rowen LC, Duncan M, Syin D, Makary MA: Impact of preoperative briefings on operating room delays: a preliminary report. Arch Surg 2008, 143 (11):10681072.
30. Patow CA, Karpovich K, Riesenberg LA, Jaeger J, Rosenfeld JC, Wittenbreer M, Padmore JS: Residents' engagement in quality improvement: a systematic review of the literature. Acad Med 2009, 84(12):17571764.
31. Jansma JD, Wagner C, Bijnen AB: A patient safety curriculum for medical residents based on the perspectives of residents and supervisors. J Patient Saf 2011, 7(2):99105.
32. Belyansky I, Martin TR, Prabhu AS, Tsirline VB, Howley LD, Phillips R, Sindram D, Heniford BT, Stefanidis D: Poor resident-attending intraoperative communication may compromise patient safety. J Surg Res 2011, 171 (2):386394.
33. Blendon RJ, DesRoches CM, Brodie M, Benson JM, Rosen AB, Schneider E, Altman DE, Zapert K, Herrmann MJ, Steffenson AE: Views of practicing physicians and the public on medical errors. N Engl J Med 2002, 347 (24):19331940.
34. Singer SJ, Gaba DM, Falwell A, Lin S, Hayes J, Baker L: Patient safety climate in 92 US hospitals: differences by work area and discipline. Med Care 2009, 47(1):2331.
35. Rosen AB, Blendon RJ, DesRoches CM, Benson JM, Bates DW, Brodie M, Altman DE, Zapert K, Steffenson AE, Schneider EC: Physicians' views of interventions to reduce medical errors: does evidence of effectiveness matter? Acad Med 2005, 80(2):189192.
36. Dunn EJ, Mills PD, Neily J, Crittenden MD, Carmack AL, Bagian JP: Medical team training: applying crew resource management in the Veterans Health Administration. Jt Comm J Qual Patient Saf 2007, 33(6):317325.
37. Guise JM, Deering SH, Kanki BG, Osterweil P, Li H, Mori M, Lowe NK: Validation of a tool to measure and promote clinical teamwork. Simul Healthc 2008, 3(4):217223.