gms | German Medical Science

Objective: Concerning surgical interventions safety of course is a major issue. It has been proven that a vast portion of hospital adverse events occurs within surgical care. We assessed elective neurosurgical interventions to document communication and workflow inside of a neurosurgical OR and to evaluate possible sources of error with a main focus of attention on supposed trivial hazard sources.

Method: In a single center 25 neurosurgical interventions were observed by an independent individual. Occurrence and direction of communication, operation of devices, confounding factors and general workflow were recorded by a specially developed workflow analysis tool running on a tablet PC complemented with photo documentation. Afterwards data was evaluated with a corresponding software application implemented for the workflow analysis tool.

Results: Communication in 69% (of the overall communication steps) took place from members of the sterile group to members of the unsterile group mainly consisting of instructions (56%). Usage of the bipolar coagulation, the operating table or the C-arm did not require as many additional steps of communication as devices like the neuronavigation, the CUSA and the duplex sonography. As the main confounding factor (reported by the independent observer as by the parties involved) ringing of the telephone was mentioned; it occurred up to 9 times per surgery, in total 109 events within 25 surgeries. Problems and significant delay in time also emerged by participation of uninitiated circulators (N=28), the absence of the circulator due to multiple duties (N=38), devices not present (N=15) and shortage of space.

Conclusions: Relatively trivial hazard sources which are easy to eliminate outnumber the more complex problems. Despite their pretended banality they are a relevant source of delay of surgery and adverse events. Analysis of surgical workflow by independent observers may contribute to acknowledge these everyday confounding factors as potentially relevant sources of error and to minimize adverse events.