Journal Article

Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical center.

Bandari J; Schumacher K; Simon M; Cameron D; Goeschel CA; Holzmueller CG; Makary MA; Welsh RJ; Berenholtz SM.

An essential part of patient safety in surgery, operating room briefings or "time-outs" are mandated by the Joint Commission as a strategy to prevent wrong-site surgery. Although briefings (and postoperative debriefings) have largely been implemented as an error prevention strategy, this study demonstrates that these structured multidisciplinary meetings can also be used to prospectively identify safety hazards. The investigators included formal documentation of any defects (concerns or problems arising at any point during the procedure) into the briefing and debriefing process, and identified equipment hazards and communication failures as among the most common sources of latent error. As organizations continue to search for methods of obtaining comprehensive safety information, data gathered in this fashion can provide an important window into patient safety hazards.