Statement on Patient Safety in the Operating Room: Team Care

The American College of Surgeons (ACS) Board of Governors Surgical Care Delivery Workgroup recently revised and updated the ACS Statement on Surgical Patient Safety to focus on team care. The original statement was developed by the Board of Governors Committee on Surgical Practice in Hospitals and Ambulatory Settings and was approved by the Board of Regents in October 2008. The Board of Regents approved the revised statement at its June 2018 meeting in Chicago, IL.

The ACS regards patient safety as a top priority. Individual hospitals and health care organizations are strongly encouraged to develop guidelines to ensure optimal patient safety in the operating room. One important component is the use of a “team approach” that engages all parties involved in the surgical process.^1,2 Whereas a lack of effective communication and failure to coordinate care are the most common causes of medical errors, incorporation of team-based practice through institutional team training is an important early step.³ One standardized curriculum is the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program developed by the U.S. Department of Defense, which focuses on leadership, situation monitoring, mutual support, and communication.⁴

Reliable methods for investing preoperative and postoperative briefing and debriefing into institutional culture should be developed. Standard processes for identification of the patient, procedure, operative consent form, and the surgical site should be mandatory and performed prior to the patient entering the operating room (OR). In the OR, a time-out or surgical pause helps avoid errors and fosters communication among surgical team members.^5,6 For procedures involving multiple surgeons, clinical team leaders or their designees are responsible for verifying the details of their portion of the operation. All relevant records, images, and essential equipment should be called out and availability confirmed. If any part of the verification process is incomplete, OR activity should be halted until verification is successfully completed.

The ACS recognizes that the use of computerized medical records and barcoding of drugs and blood products are highly desirable throughout all perioperative areas. Computerized preference cards help avoid multiple trips by support staff from the OR during the procedure. It also is important that during high-risk portions of procedures, the team should agree on specific no-handoff times during which certain members of the team will not be changed. Safe practices as recommended by the ACS and The Joint Commission—including, but not limited to, double-gloving, blunt-tip suture needles, neutral zones, and protective sharps devices—protect team members and the patient.⁷ In addition, the ACS condemns disruptive behavior from any member of the OR team, as such behavior jeopardizes patient safety.⁸

To enhance patient safety, it is the responsibility of the surgeon to engage in the following activities:

• Oversee proper preoperative preparation of the patient with standardized perioperative care protocols
• Obtain informed consent from the patient or patient’s representative relative to the indications and conduct of the operation
• Lead the surgical team to confirm the diagnosis, agreed upon operation, fire risk, and all other appropriate components of the time-out
• Consult with anesthesia and nursing staff team members to ensure safe patient positioning and padding
• Perform the operation safely and competently, including planning the optimal anesthesia and postoperative analgesia method with the anesthesia team
• Confirm the wound classification at the completion of the procedure
• Oversee specimen labeling and management with completion of the pathology requisition
• Disclose operative findings and the expected postoperative course to the patient and/or patient’s representative
• Provide postoperative care of the patient, including personal participation in the direction of this care and management of postoperative complications should they occur

Disclaimer

The ACS offers this statement for consideration by surgeons, their hospitals, and health care organizations. This statement is provided as general guidance. It does not constitute a standard of care and is not intended to replace the professional judgment of the surgeon or health care administrator.

This statement may be reviewed and modified as necessary to conform with the laws of the applicable jurisdiction, the circumstances of the individual hospital and health care organization, and the requirements of other allied and health care organizations.

Additional College Statements on This topic

Related statements include the following:

• Statement on Advance Directives by Patients: “Do Not Resuscitate” in the Operating Room
• Statement on Distractions in the Operating Room
• Statement on Health Care Industry Representatives in the Operating Room
• Statement on Operating Room Attire
• Statement on Patient Safety Principles for Office-Based Surgery Utilizing Moderate Sedation/Analgesia, Deep Sedation/Analgesia, or General Anesthesia
• Statement on Safe Surgery Checklists, and Ensuring Correct Patient, Correct Site, and Correct Procedure Surgery
• Statement on Sharps Safety

References

1. Healy GB, Barker J, Madonna G. Error reduction through team leadership: Seven principles of CRM applied to surgery. Bull Am Coll Surg. 2006;91(2):24-26.
2. McKeon LM, Cunningham PD, Oswaks JS. Improving patient safety: Patient-focused, high-reliability team training. J Nurs Care Qual. 2009;24(1):76-82.
3. Meier AH. Team training in surgical education: The successful surgeon of the future needs to be a team player. Resources in Surgical Education. Available at: facs.org/education/division-of-education/publications/rise/articles/rap-archive/team-training-in-surgical-education-the-successful-surgeon-of-the-future-needs-to-be-a-team-player. Accessed July 30, 2018.
4. Clancy CM, Tornberg DN. TeamSTEPPS: Assuring optimal teamwork in clinical settings. Am J Med Qual. 2007;22(3):214-217.
5. World Health Organization. WHO guidelines for safe surgery 2009: Safe Surgery Saves Lives. Available at: http://apps.who.int/iris/bitstream/10665/44185/1/9789241598552_eng.pdf. Accessed July 30, 2018.
6. World Health Organization. World Alliance for Patient Safety Implementation Manual Surgical Safety Checklist (First edition): Safe Surgery Saves Lives. Available at: who.int/patientsafety/safesurgery/tools_resources/SSSL_Manual_finalJun08.pdf. Accessed July 30, 2018.
7. American College of Surgeons. ACS Revised Statement on Sharps Safety. Available at: facs.org/about-acs/statements/94-sharps-safety. Accessed July 30, 2018.
8. Santin BJ, Kaups KA. The disruptive physician: Addressing the issues. Bull Am Coll Surg. 2015;100(2):20-24.

Reprinted from Bulletin of the American College of Surgeons
Vol. 103, No. 9, September 2018