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The newspaper of The Johns Hopkins University May 8, 2006 | Vol. 35 No. 33
Study of OR teamwork shows nurses rate first, surgeons last

By Eric Vohr
Johns Hopkins Medicine

A study based on a survey measuring attitudes toward the work environment in the operating room reveals that surgeons exhibit the lowest level of teamwork and nurses the highest.

The survey, called the Safety Attitudes Questionnaire, was adapted from an airline industry questionnaire and applied to the health care environment. Developed by a Johns Hopkins-led team, the SAQ contains 65 questions in six areas relating to safety, including teamwork climate, safety climate, job satisfaction, perceptions of management, stress recognition and working conditions. Results appear in the May issues of the Annals of Surgery and the Journal of the American College of Surgeons.

Only 65 percent of OR personnel thought surgeons exhibited a high or very high level of teamwork. In contrast, 83.5 percent of those surveyed believed general surgical nurses exhibit a high or very high level of teamwork, and 85 percent rated certified registered nurse anesthetists, or CRNAs, as showing a high or very high level of teamwork. Anesthesiologists rated third at 79 percent.

"The SAQ provides hospitals with an accurate method for rating safety in the OR because it asks frontline caregivers about the OR work environment," said lead researcher Martin Makary, an assistant professor in the Department of Surgery at the School of Medicine. "Results — like those telling us that surgeons rate poorly in teamwork — help target areas for improved communication and provide a benchmark for rating strategies aimed at improving patient safety."

Makary said that other questions, such as ones directly asking OR team members if they would feel comfortable being operated on in their own hospitals, send a clear message regarding patient safety concerns in the OR.

"The bottom line is, you wouldn't want to fly with a pilot or co-pilot who wasn't happy with his working environment, and the same applies to the OR," he said.

The SAQ was adapted from the Flight Management Attitudes Questionnaire and its predecessor, the Cockpit Management Attitudes Questionnaire, both of which were developed to address accidents in the airline industry. The theory behind all these surveys is that improving work-area issues improves safety, said co-researcher J. Bryan Sexton, an assistant professor of anesthesiology and critical care medicine at Johns Hopkins. The survey is not limited to the OR. Variations of the SAQ have been used to analyze work environments throughout the hospital, he said.

"We found that using frontline caregiver assessments of patient safety can give you a valid and reliable consensus on how things are going in a particular patient care area, and that this is related to important outcomes like hospital-acquired infections, length of stay and nurse turnover," Sexton said.

Reports by the Institute of Medicine regarding safety in the OR, rising malpractice costs and the demonstrated vulnerability and devastation hospitals face after public exposure of deaths due to OR errors have all drawn attention to the importance of developing sound hospital systems to reduce OR errors. As a result, the Joint Commission on Accreditation of Healthcare Organizations will require all hospitals to measure their culture beginning in 2007.

Wrong site/wrong procedure surgeries, retained sponges, unchecked blood transfusions, mismatched organ transplants and overlooked allergies are examples of potentially catastrophic events that, in certain circumstances, can be prevented by improved communication and safer hospital systems.

The team fine-tuned the SAQ by reviewing the literature on patient safety, asking OR health care providers to review the survey and conducting focus groups.

These SAQ questions were presented to all OR caregivers in a Catholic health system comprising 60 hospitals in 16 states during July and August 2004. Results were gathered from 222 surgeons, 1,058 OR nurses, 564 surgical technicians, 170 anesthesiologists and 121 CRNAs. On each question on teamwork, participants were asked to rate themselves and their peer groups on a scale of 1 (very low) to 5 (very high). The overall response rate was 77.1 percent.

"The results have already led to improvements in the OR," Makary said. "Before every operation, we now require a pre-surgery checklist similar to what pilots do before take-off. This not only minimizes errors but also improves teamwork."

Makary said 700 hospitals are already using the survey, and he expects to see more adapting it in the near future.

This study was conducted with a grant from the Agency for Healthcare Research and Quality.

Other Johns Hopkins investigators involved in the study are Julie A. Freischlag, chief of Surgery, SoM; Peter J. Pronovost, professor, and Christine Holzmueller, senior research program coordinator, Department of Anesthesiology and Critical Care Medicine, SoM; E. Anne Millman, research associate, Bloomberg School of Public Health; and Lisa Rowen, Surgical Nursing director, JHH. David B. Pryor, senior vice president for clinical excellence at Ascension Health Systems in St. Louis, Mo., also contributed to the study.


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