Real Event Learning and Analysis (REAL): Assessing and Improving Surgical Team Performance
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Waters, Peter M.
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CitationWaters, Peter M. 2019. Real Event Learning and Analysis (REAL): Assessing and Improving Surgical Team Performance. Master's thesis, Harvard Medical School.
AbstractErrors in surgery can have serious consequences to the patient’s health, surgical teams’ liability, and hospital reputation. Despite Joint Commission on Accreditation of Healthcare Organizations (JACHO) clear mandates and regulations to lessen risk, errors continue to occur at significant rates for unclear reasons. A stark example, wrong site/wrong procedure/wrong patient (WSPEs), are incidents that should be preventable or at least made exceedingly rare. US Department of Health and Human Resources Agency for Healthcare Research and Quality (AHRQ) maintains a WSPEs should constitute a “never” event. However, WSPEs continue to occur despite World Health Organization (WHO) structured universal protocols designed to prevent them.
By establishing highly reliable cultures of individual and team training, simulation can be effective in improving communication, leadership, task management, and situational awareness. An evolution of this process is to leverage these psychological safety strategies and debriefing skills to understand live performance at the point of clinical care delivery.
The REAL (Real Event Analysis and Learning) live observational and audiovisual analysis project was developed to achieve this goal - namely to create a transformable system to achieve strong proof of concept, study and evaluate the benefits of live video capture in the operating rooms as an important patient safety/QI/QA target. REAL required many complex, iterative steps to implementation including: (1) approval and support by hospital executive, anesthesia, surgical, nursing and legal leadership; (2) hospital IRB classification and approval of REAL as a quality improvement project; (3) acceptance and active participation by the operating room professional staff in REAL; and (4) technical expertise to record 360 degree visual and auditory activities from start to finish of each procedure observed and analyzed. All were achieved.
Our findings in the Phase I pilot (3 surgical days and 11 operative cases by single surgeon) confirmed feasibility of REAL. Our findings in Phase II involved 8 operative days ( (> 50 hours) of skin to skin surgery time) of surgical care for 24 patients by 4 different surgeons and multiple, variable anesthesia and nursing teams demonstrated: (1) live OR analysis is feasible and scalable; (2) team performance as assessed live in OR and by audiovisual analysis is comparable; (3) staff acceptance of live performance analysis and learning occurred, including dedication to betterment as evidenced in debriefings; (4) performance of universal protocols is variable and often incomplete; and (5) non-technical performance by nursing, anesthesia, and nursing was high but there were both at risk (safety 1) and commendable unexpected (safety 2) behaviors. Thus, audio/visual capture of live events even in an institution dedicated to patient safety and high reliability and performing at a high level as noted by validated tools, there is still risk of WSPEs, and less serious errors. Next steps are to build on our now higher-level platform of psychology safety in REAL to achieve growth in operating room team learning and performance, to further lessen error risk, enhance safety, and build even more reliable care teams.
Citable link to this pagehttps://nrs.harvard.edu/URN-3:HUL.INSTREPOS:37365293