Surgical briefings, checklists, and the creation of an environment of safety in the neurosurgical intraoperative magnetic resonance imaging suite

Neurosurgical Focus

Volumn 33, Issue 5, 2012, Pages

  Rahmathulla, Gazanfar ^a   Recinos, Pablo F ^a,b   Traul, David E ^a   Avitsian, Rafi ^a   Yunak, Marisa ^a   Harper, Nicole T ^a   Barnett, Gene H ^a   Recinos, Violette Renard ^a  

^a LERNER RESEARCH INSTITUTE   (United States)

^b JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE   (United States)

Author keywords

Checklist; Intraoperative magnetic resonance imaging; Operating room safety

Indexed keywords

ANESTHESIA; CHECKLIST; COMPUTER SYSTEM; ELECTROMAGNETIC FIELD; HUMAN; INSTRUMENTATION; MEDICAL ERROR; METHODOLOGY; NEUROSURGERY; NUCLEAR MAGNETIC RESONANCE IMAGING; OPERATING ROOM; ORGANIZATION AND MANAGEMENT; PATIENT SAFETY; REVIEW;

ANESTHESIA; CHECKLIST; COMPUTER SYSTEMS; ELECTROMAGNETIC FIELDS; HUMANS; MAGNETIC RESONANCE IMAGING; MEDICAL ERRORS; NEUROSURGICAL PROCEDURES; OPERATING ROOMS; PATIENT SAFETY;

EID: 84871994693     PISSN: None     EISSN: 10920684     Source Type: Journal    
DOI: 10.3171/2012.9.FOCUS12260     Document Type: Article

References (45)

1. Black PM, Moriarty T, Alexander E III, Stieg P, Woodard EJ, Gleason PL, et al: Development and implementation of intraoperative magnetic resonance imaging and its neurosurgical applications. Neurosurgery 41:831-845, 1997
2. Bosk CL, Dixon-Woods M, Goeschel CA, Pronovost PJ: Reality check for checklists. Lancet 374:444-445, 2009
3. Brooke BS, Meguid RA, Makary MA, Perler BA, Pronovost PJ, Pawlik TM: Improving surgical outcomes through adoption of evidence-based process measures: intervention specific or associated with overall hospital quality? Surgery 147:481-490, 2010
4. Chaljub G, Kramer LA, Johnson RF III, Johnson RF Jr, Singh H, Crow WN: Projectile cylinder accidents resulting from the presence of ferromagnetic nitrous oxide or oxygen tanks in the MR suite. AJR Am J Roentgenol 177:27-30, 2001
5. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA: The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 17:216-223, 2008
6. De Wilde JP, Grainger D, Price DL, Renaud C: Magnetic resonance imaging safety issues including an analysis of recorded incidents within the UK. Prog Nucl Magn Reson Spectrosc 51:37-48, 2007
7. Department of Health and Human Services: Partnership for patients to improve care and lower costs for Americans [news release]. Washington, DC: US Department of Health and Human Services, April 12, 2011 (http://www.hhs.gov/news/press/2011pres/04/20110412a.html) [Accessed October 1, 2012]
8. Donaldson LJ: The quest for safer surgery. Surgeon 5:324-326, 2007
9. Fletcher G, Flin R, McGeorge P, Glavin R, Maran N, Patey R: Anaesthetists' Non-Technical Skills (ANTS): evaluation of a behavioural marker system. Br J Anaesth 90:580-588, 2003
10. Griffin FA, Classen DC: Detection of adverse events in surgical patients using the Trigger Tool approach. Qual Saf Health Care 17:253-258, 2008
11. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al: A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360:491-499, 2009
12. Helmreich RL: Culture and error in space: implications from analog environments. Aviat Space Environ Med 71 (9 Suppl): A133-A139, 2000
13. Helmreich RL: Managing human error in aviation. Sci Am 276:62-67, 1997
14. Helmreich RL: On error management: lessons from aviation. BMJ 320:781-785, 2000
15. Helmreich RL, Merritt AC, Wilhelm JA: The evolution of Crew Resource Management training in commercial aviation. Int J Aviat Psychol 9:19-32, 1999
16. Henrichs B, Walsh RP: Intraoperative magnetic resonance imaging for neurosurgical procedures: anesthetic implications. AANA J 79:71-77, 2011
17. Johnston T, Moser R, Moeller K, Moriarty TM: Intraoperative MRI: safety. Neurosurg Clin N Am 20:147-153, 200
18. Kajita Y, Fujii M, Yoshida J, Maesawa S: [Image-guided neurosurgery for brain tumor: a current perspective.] No Shinkei Geka 36:443-456, 2008 (Jpn)
19. Kanal E, Shellock FG, Talagala L: Safety considerations in MR imaging. Radiology 176:593-606, 1990
20. King HB, Battles J, Baker DP, Alonso A, Salas E, Webster J, et al: TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety. (http://www.ahrq.gov/downloads/pub/advances2/vol3/Advances-King_1.pdf) [Accessed October 1, 2012]
21. Klucznik RP, Carrier DA, Pyka R, Haid RW: Placement of a ferromagnetic intracerebral aneurysm clip in a magnetic field with a fatal outcome. Radiology 187:855-856, 1993
22. Kohn LT, Corrigan J, Donaldson MS (eds): To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press, 2000, Vol 6
23. Levy R, Cox RG, Hader WJ, Myles T, Sutherland GR, Hamilton MG: Application of intraoperative high-field magnetic resonance imaging in pediatric neurosurgery. Clinical article. J Neurosurg Pediatr 4:467-474, 2009
24. Maesawa S, Fujii M, Nakahara N, Watanabe T, Saito K, Kajita Y, et al: Clinical indications for high-field 1.5 T intraoperative magnetic resonance imaging and neuro-navigation for neurosurgical procedures. Review of initial 100 cases. Neurol Med Chir (Tokyo) 49:340-350, 2009
25. Mahajan RP: The WHO surgical checklist. Best Pract Res Clin Anaesthesiol 25:161-168, 2011
26. Makary MA, Mukherjee A, Sexton JB, Syin D, Goodrich E, Hartmann E, et al: Operating room briefings and wrong-site surgery. J Am Coll Surg 204:236-243, 2007
27. Makary MA, Sexton JB, Freischlag JA, Holzmueller CG, Millman EA, Rowen L, et al: Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder. J Am Coll Surg 202:746-752, 2006
28. Makary MA, Sexton JB, Freischlag JA, Millman EA, Pryor D, Holzmueller C, et al: Patient safety in surgery. Ann Surg 243:628-635, 2006
29. Menon DK, Peden CJ, Hall AS, Sargentoni J, Whitwam JG: Magnetic resonance for the anaesthetist. Part I: Physical principles, applications, safety aspects. Anaesthesia 47:240-255, 1992
30. Morey JC, Simon R, Jay GD, Wears RL, Salisbury M, Dukes KA, et al: Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health Serv Res 37:1553-1581, 2002
31. Nimsky C, Ganslandt O, Kober H, Buchfelder M, Fahlbusch R: Intraoperative magnetic resonance imaging combined with neuronavigation: a new concept. Neurosurgery 48:1082-1091, 2001
32. Nimsky C, Ganslandt O, von Keller B, Fahlbusch R: Intraoperative high-field MRI: anatomical and functional imaging. Acta Neurochir Suppl 98:87-95, 2006
33. Sax HC: Improving patient safety with the use of surgical checklists. Med Health R I 92:265-266, 2009
34. Shellock FG: Biological effects and safety aspects of magnetic resonance imaging. Magn Reson Q 5:243-261, 1989
35. Shellock FG: Reference Manual for Magnetic Resonance Safety. Salt Lake City: Amirsys, 2003
36. Shellock FG, Bierman H: The safety of MRI. JAMA 261: 3412, 1989 (Letter)
37. Shellock FG, Crues JV: MR procedures: biologic effects, safety, and patient care. Radiology 232:635-652, 2004
38. Smith JA: Hazards, safety, and anesthetic considerations for magnetic resonance imaging. Top Companion Anim Med 25:98-106, 2010
39. Steinmeier R, Fahlbusch R, Ganslandt O, Nimsky C, Buchfelder M, Kaus M, et al: Intraoperative magnetic resonance imaging with the Magnetom open scanner: concepts, neurosurgical indications, and procedures: a preliminary report. Neurosurgery 43:739-748, 1998
40. Sutherland GR, Kaibara T, Louw D, Hoult DI, Tomanek B, Saunders J: A mobile high-field magnetic resonance system for neurosurgery. J Neurosurg 91:804-813, 1999
41. Sutherland GR, Louw DF: Intraoperative MRI: a moving magnet. CMAJ 161:1293, 1999
42. Tan TK, Goh J: The anaesthetist's role in the setting up of an intraoperative MR imaging facility. Singapore Med J 50:4-10, 2009
43. Thomassen O, Brattebø G, Heltne J-K, Søfteland E, Espeland A: Checklists in the operating room: Help or hurdle? A qualitative study on health workers' experiences. BMC Health Serv Res 10:342, 2010
44. Vincent C, Neale G, Woloshynowych M: Adverse events in British hospitals: preliminary retrospective record revie. BMJ 322:517-519, 2001
45. Wilson I, Walker I: The WHO Surgical Safety Checklist: the evidence. J Perioper Pract 19:362-364, 2009