• Skip to primary navigation
  • Skip to main content
  • Skip to footer

SAGES

Reimagining surgical care for a healthier world

  • Home
    • Search
    • SAGES Home
    • SAGES Foundation Home
  • About
    • Who is SAGES?
    • SAGES Mission Statement
    • Advocacy
    • Strategic Plan, 2020-2023
    • Committees
      • Request to Join a SAGES Committee
      • SAGES Board of Governors
      • Officers and Representatives of the Society
      • Committee Chairs and Co-Chairs
      • Full Committee Rosters
      • SAGES Past Presidents
    • Donate to the SAGES Foundation
    • SAGES Store
    • Awards
      • George Berci Award
      • Pioneer in Surgical Endoscopy
      • Excellence In Clinical Care
      • International Ambassador
      • IRCAD Visiting Fellowship
      • Social Justice and Health Equity
      • Excellence in Community Surgery
      • Distinguished Service
      • Early Career Researcher
      • Researcher in Training
      • Jeff Ponsky Master Educator
      • Excellence in Medical Leadership
      • Barbara Berci Memorial Award
      • Brandeis Scholarship
      • Advocacy Summit
      • RAFT Annual Meeting Abstract Contest and Awards
    • “Unofficial” Logo Products
  • Meetings
    • NBT Innovation Weekend
    • SAGES Annual Meeting
      • 2024 Scientific Session Call For Abstracts
      • 2024 Emerging Technology Call For Abstracts
    • CME Claim Form
    • Industry
      • Advertising Opportunities
      • Exhibit Opportunities
      • Sponsorship Opportunities
    • Future Meetings
    • Related Meetings Calendar
  • Join SAGES!
    • Membership Benefits
    • Membership Applications
      • Active Membership
      • Affiliate Membership
      • Associate Active Membership
      • Candidate Membership
      • International Membership
      • Medical Student Membership
    • Member News
      • Member Spotlight
      • Give the Gift of SAGES Membership
  • Patients
    • Healthy Sooner – Patient Information for Minimally Invasive Surgery
    • Patient Information Brochures
    • Choosing Wisely – An Initiative of the ABIM Foundation
    • All in the Recovery: Colorectal Cancer Alliance
    • Find a SAGES Member
  • Publications
    • SAGES Stories Podcast
    • SAGES Clinical / Practice / Training Guidelines, Statements, and Standards of Practice
    • Patient Information Brochures
    • TAVAC – Technology and Value Assessments
    • Surgical Endoscopy and Other Journal Information
    • SAGES Manuals
    • SCOPE – The SAGES Newsletter
    • COVID-19 Annoucements
    • Troubleshooting Guides
  • Education
    • OpiVoid.org
    • SAGES.TV Video Library
    • Safe Cholecystectomy Program
      • Safe Cholecystectomy Didactic Modules
    • Masters Program
      • SAGES Facebook Program Collaboratives
      • Acute Care Surgery
      • Bariatric
      • Biliary
      • Colorectal
      • Flexible Endoscopy (upper or lower)
      • Foregut
      • Hernia
      • Robotics
    • Educational Opportunities
    • HPB/Solid Organ Program
    • Courses for Residents
      • Advanced Courses
      • Basic Courses
    • Fellows Career Development Course
    • Robotics Fellows Course
    • MIS Fellows Course
    • Facebook Livestreams
    • Free Webinars For Residents
    • SMART Enhanced Recovery Program
    • SAGES OR SAFETY Video
    • SAGES at Cine-Med
      • SAGES Top 21 MIS Procedures
      • SAGES Pearls
      • SAGES Flexible Endoscopy 101
      • SAGES Tips & Tricks of the Top 21
  • Opportunities
    • NEW-Area of Concentrated Training Seal (ACT)-Advanced Flexible Endoscopy
    • SAGES Fellowship Certification for Advanced GI MIS and Comprehensive Flexible Endoscopy
    • Multi-Society Foregut Fellowship Certification
    • SAGES Research Opportunities
    • Fundamentals of Laparoscopic Surgery
    • Fundamentals of Endoscopic Surgery
    • Fundamental Use of Surgical Energy
    • Job Board
    • SAGES Go Global: Global Affairs and Humanitarian Efforts
  • Search
    • Search All SAGES Content
    • Search SAGES Guidelines
    • Search the Video Library
    • Search the Image Library
    • Search the Abstracts Archive
  • OWLS
  • Log In

Implementing a tool for structured postoperative team debriefing to improve surgical safety.

Anne Sophie van Dalen1, Teodor Grantcharov, MD, PhD2, Marlies P Schijven, MD, PhD, MHSc1. 1Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, The Netherlands, 2International Centre for Surgical Safety, Li Ka Shing Knowledge Institute of St. Michael’s Hospital

OBJECTIVE Intraoperative adverse events are a major safety threat in modern surgery. A significant number of these adverse events are preventable, however their true incidence is still unknown and they are not systematically reported and studied. The objective was to use the OR Black Box®, a medical data recorder in the operating room, to analyse safety threats and resilience events in elective laparoscopic abdominal procedures. We compared the events registered by the system with the instances observed and reported by the team during a multi-disciplinary post-operative debriefing.

PROJECT DESCRIPTION AND METHODS The Surgical Team Assessment Record (STAR) post-operative questionnaire was used. Recordings were analysed by a combination of Artificial Intelligence algorithms and trained analysis team of surgeons and human factor specialists. Validated measurement instruments were used, namely the Systems Engineering Initiative for Patient Safety (SEIPS) framework, Non-Technical Skills for Surgeons (NOTSS) and Scrub Practitioners' List of Intraoperative Non-Technical Skills (SPLINTS) system. According to the SEIPS model, the observed events were classified into 6 sociotechnical, human-centered interacting components that influence performance; person(s), tasks, tools and technologies, organization, internal environment, and external environment. Procedures were debriefed using the OR Black Box® standardized performance report, which included a video clip summarizing all relevant positive and negative observed events. A standardized debrief model was developed. The participating team members, which included the surgeons, anaesthesiologists, residents, nurses and medical students, were asked to fill out a questionnaire after the debriefing as well, to measure their satisfaction with the use of a Black Box and its performance report, used as a tool for structured team debriefing.

RESULTS Thirty-five procedures were included. In total, 404 threats were identified and described in the Black Box performance report. A mean number of 52.5 (SD 15.0) relevant positive and negative events per surgical procedure were identified, of which on average 11.5 (SD 4.2) were rated as safety threats. According to the answers of the STAR questionnaire (N=234), in only 26.5% (n=65) of times the operating team members indicated that they had noticed aberrations during the surgical case. During the debriefings, the majority of the discussed adverse events and lessons-learned were concerning (mis)communication and teamwork. In 98% of times, the participating operating theatre staff (N=81), would recommend the Black Box team debriefings to their colleagues.

CONCLUSION: The use of the OR Black Box® and its performance report for postoperative team debriefing was highly recommended. Team debriefing may help the team to recognize, understand and learn from clinically relevant but unnoticed or unreported safety threats and resilience support events. Postoperative structured team debriefing may also be important for resolving incorrect assumptions between theatre staff members to avoid future unnecessary miscommunication.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 98632

Program Number: ET011

Presentation Session: Emerging Technology Session

Presentation Type: Podium

175

Share this:

  • Twitter
  • Facebook
  • LinkedIn
  • Pinterest
  • WhatsApp
  • Reddit

Related

Hours & Info

11300 West Olympic Blvd, Suite 600
Los Angeles, CA 90064
1-310-437-0544
[email protected]
Monday - Friday
8am to 5pm Pacific Time

Find Us Around the Web!

  • Facebook
  • Twitter
  • YouTube

Important Links

SAGES 2023 Meeting Information

Healthy Sooner: Patient Information

SAGES Guidelines, Statements, & Standards of Practice

SAGES Manuals

 

  • taTME Study Info
  • Foundation
  • SAGES.TV
  • MyCME
  • Educational Activities

Copyright © 2023 Society of American Gastrointestinal and Endoscopic Surgeons