Incidents reported by nurse anaesthetists in the operating room

ABSTRACT

The quality of health care and patient safety in the operating room is a major concern for nurse anaesthetists. However, few studies have focused on the experiences of nurse anaesthetists’ and their contributions to safety in this setting. Therefore, this study aims to explore the content and frequency of incidents reported by nurse anaesthetists in the operating room and the risks involved in these incidents. A retrospective study with a descriptive design was conduct. Data were gathered concerning 220 incidents reported by nurse anaesthetists from 2012 to 2015 in operating rooms at a middle-sized hospital in Sweden. These were analysed with a method for qualitative and quantitative content analysis. The findings are presented in five categories: communication and teamwork; routines and guidelines; patient care; nurses’ work environment; devices, materials and technologies. In 184 (73%) of the incidents, there was either a risk of harm or there was an actual harm to patients or nurses. Of all incidents only 23 (10%) had harmed patients or nurses. Few of these incidents involved patient harm (n = 6), while a greater number involved harm to nurses (n = 17). The findings reveal lack of communication and interprofessional teamwork as the two most common areas for the reported incidents, followed by problems related to lack of compliance with guidelines and routines. The findings suggest that strategies are needed to improve these areas. Patient safety reporting systems may be important to identify risk in preventing patients and health care professionals from being harmed. In addition, the findings indicate that the nurses sought to prevent harm to patients rather than to themselves. Consequently, increased attention to the work environments of nurses, and most likely other professionals, in the operating room may be needed to prevent health care professionals from being harmed.

Keywords:

• incidents
• patient safety
• quality improvement
• nurses
• operating room
• content analysis

Introduction

The quality of health care and patient safety is a major concern for teams working together in the operating room. Over the past decade, the importance of reducing incidents and preventing harm to patients and health care professionals has been stressed (Chassin & Galvin, 1998; Leape, 2002). Substantial efforts have been made to safeguard the quality of health care and prevent harms. For instance, patient safety reporting systems (PSRS) have been widely implemented to identify risks and prevent harm to patients and other individuals in the health care setting (Leape, 2002; Pronovost et al., 2006). PSRS is thus important in enhancing patient safety by learning from failures, and to provide knowledge helping professionals to do safe work. In Sweden, where this study was conducted, health care organisations are legally required to have routines for patient safety and quality improvement, of which the PSRS is a cornerstone. Although actions been taken to save lives by achieving patient safety and safe surgery (WHO, 2017), less attention has been paid to the nurse anaesthetists’ (NA) role in patient safety, in spite of the pivotal role these providers play providing care in operating rooms in many countries around the world. As a result, little is known about incidents reported by NAs in the operating room, and what can be learned from such reports. Therefore, this study was conducted.

Background

Maintaining a culture that values and strives for patient safety and quality improvement should be prioritised (European commission, 2014). There may however be challenges to get sustained quality improvements (Herzer et al., 2012). Even reliable organisations are not immune to possible risks and constantly need to learn how to prevent harmful events. Many factors can contribute to such risks and incidents, and data on PSRS can be used to prevent errors and ensure patient safety (Leape, 2002; Pronovost et al., 2006).

It is well known that health care is not error-free and is delivered by teams who need to work effectively to deliver safe patient care (Kohn, Corrigan, & Donaldson, 1999). When errors occur, such incidents can be approached from the point of view of either the person or the system. The consequences of these approaches are different. The former approach focuses on the individual, and when an event occurs the individual is blamed. On the contrary, a system approach focuses on the organisation and the conditions under which individuals work, and when an event occurs the latter approach focuses on the system questioning why something happened and how it was possible (Reason, 2000).

The NAs are part of the interprofessional team working together in the operating room. In Sweden where this study was conducted, certified registered NAs have a second cycle higher education upon graduation as nurses. A main responsibility of NAs is to ensure patient safety (Alfredsdottir & Bjornsdottir, 2007) together with professionals in the operating team. The working environment in this setting is a technological, caring environment where patient safety is of the utmost importance. Some main factors contributing to safer patient care in the operating room is the communication and teamwork of these professionals (Gillespie, Gwinner, Chaboyer, & Fairweather, 2013). The optimal performance of teams may rely on open discussions among the teams working together regarding their expectations. It has been stressed that teamwork and patient safety can be improved following education and training (Wallin et al., 2015). In addition, education and training can have longitudinal effects in changing values and attitudes towards teamwork and in shaping a culture of safety in operating rooms (Bleakley, Allard, & Hobbs, 2012). The communication within teams is one of several indicators that have been described as positively affecting co-operative and working relationships in interprofessional teams (Molyneux, 2001). Effective communication to understand professional roles and responsibilities are important to enhance a patient-centred collaborative practice (Suter et al., 2009). One observational study (Christian et al., 2006) of operating rooms found problems in communication and information flow. The study also reports that workload and competing tasks posed the greatest threats to patient safety. Similarly, Chakravarty (2013) called attention to the importance of those who provide care because they have an interest in patient safety and in reducing medical errors made in the hospital. Many errors are related to routines not being followed, lack of knowledge on how to use devices or devices being defect, which put both the health care professionals and the patient at risk. Furthermore, NAs in operating rooms may be confronted by the same risks. Although the focus of NAs in this setting is mainly technical, nursing care also involves interpersonal relationships and the responsibility for the quality of care and patient safety (Bull & FitzGerald, 2006).

Understanding of NAs potential contributions to patient safety in the operating room is limited. To our knowledge, there are few studies on patient safety reports in this setting taking into account the NAs perspective. Therefore, this study was conducted to identify areas of safety in the operating room to learn from incident reports. The objectives of the study were to explore the content and frequency of incidents reported by NAs in the operating room and the risks involved in these incidents.

Methods

Design

A retrospective study with a descriptive design was conducted to explore incidents reported through the PSRS used in an operating unit at a Swedish hospital. From all incidents reported on potential harms, risks and/or adverse events, a sample was selected based on incidents reported by NAs in the operating room. These were analysed with a method for content analysis of qualitative and quantitative patterns in the data (Krippendorff, 2013; Morgan, 1993).

Sample and setting

The sample included all incidents in the period from 2012 to 2015 that were voluntarily reported by certified registered NAs working in operating rooms at a middle-sized hospital serving a population of 297,000 inhabitants in the south west of Sweden. The data were gathered from an electronic PSRS used at the hospital for the reporting of incidents. In this system, the reporter provides answers to predefined questions by checking the appropriate boxes or by providing a written description of the incident. The incidents comprised any undesirable event that occurred in the care of patients, which could or did lead to risks to patient safety or adverse events.

Data collection

The data were collected in 2016 from the PSRS with the help of the unit’s controller. All data on patients and health care professionals were anonymous when handed out from the PSRS. From a total sample of 1,575 reported incidents, 220 incidents were included in the study, based on the inclusion criteria: all incidents in operating rooms reported by NAs in the years 2012, 2013, 2014 and 2015. The exclusion criteria were incidents reported by other health care professionals or incidents related to situations on other wards or that occurred before the patient entered the operating room. In Figure 1, the flow diagram shows the number of incidents reported, included and excluded and the reasons for the exclusion.

Figure 1. Flow diagram of incidents reported, included and excluded and the reasons for exclusion.

Data analysis

In this study, the content analysis used a descriptive process that focused on locating qualitative and quantitative patterns that emerged in the data. This process involved two analytic phases: a coding process and a counting process. The first qualitative phase focused on the content, that is, what was in the data, and the latter focused on quantitative aspects such as frequency and the amount of incidents related to categories and subcategories (Krippendorff, 2013; Morgan, 1993).

First, a qualitative analysis was conducted to explore the content of the data. In this phase, the incidents reported were carefully examined by two of the authors (EJ & LJ), reading the incidents repeated times. The original text of the reports was used as the source for categories and subcategories. During the first step of the analysis, the content of the reported incidents was marked and coded. The understanding of the incidents and codes made were reviewed and discussed among three of the authors (AJS, EJ & LJ). The codes were compared for differences and similarities, and emerging patterns were identified. From the coding categories and subcategories were derived and modified. This process resulted in five categories and seventeen related subcategories.

Thereafter, a quantitative analysis was performed to describe the amount of reports related to the patterns found in the qualitative analysis. The frequencies of the reported incidents related to different categories was counted by two of the authors (EJ & LJ), and further discussed with the third author (AJS) and related to the codes and categories from the qualitative analysis. These frequencies are presented as empirical results.

The analysis was mainly performed by two of the authors, with a third author following every step in the analysis. These analyses were than validated by the fourth author, who read and gave comments. All authors read and commented on the final version of the analysis to ensure rigour and the validity of the findings.

Ethical considerations

This study followed the ethical regulations and guidelines according to Swedish law (Sweden, The Ministry of Education and Research, 2003). It conformed to the Declaration of Helsinki (World Medical Association, 2008) and complied with the ethical standards for research, including the respect for confidentiality. Before the study was conducted the head of the anaesthesia care unit gave written informed consent for the study. The data were collected from a PSRS, and no data included the names, identities or personal information on NAs, patients or other persons who took part in the incidents analysed in this study.

Results

Sample description

A total of 220 reported incidents were analysed. The reported incidents took place in the period from 2012 to 2015. The NAs were responsible for 56.7% of all incidents reported by nurses. Incidents were mainly reported during weekdays (n = 212, 96%), and the majority was reported during the day between 7:00 a.m. and 4:00 p.m. (n = 160, 73%).

Description of the incidents in operating rooms reported by NAs

Five categories of the content of the reported incidents emerged from the analysis: 1) communication and teamwork; 2) routines and guidelines; 3) patient care; 4) NAs work environment; 5) devices, materials and technologies (see Table 1).

Table 1. Descriptions of categories and subcategories with number and percent of incidents reported.

CATEGORIES	SUBCATEGORIES	NO. OF INCIDENTS	% OF ALL INCIDENTS
Communication and teamwork	Communication Medical record keeping Teamwork Drug prescriptions	62	28,2
Routines and guidelines	Drugs or materials Noncompliance of guidelines	60	27,3
The patient care	Drug managements Patient identification errors Anaesthesia or surgical adverse events Language and interpreter Information	47	21,3
The NAs work environment	The physical work environment The psychosocial work environment	27	12,3
Devices, materials, and technologies	Devices Materials False alarms Computers	24	10,9
Total		220	100

Communication and teamwork

This category contained 62 reported incidents (28%). These incidents were coded in one of four subcategories: communication (n = 26); medical record keeping (n = 20); teamwork (n = 12); drug prescriptions (n = 4). The subcategory communication included incidents related to insufficient or inadequate information being exchanged between NAs and health care professionals within the operating team or at other departments or clinics. Communication problems occurred in different situations with these professionals regarding the patient or the operation. Incidents related to medical record keeping in the operating room included poor notes on patients’ conditions, missing information regarding patients’ allergies, the wrong patient’s record and insufficient information about preoperative care. Incidents involving teamwork occurred as problems or delays related to the operating team. For instance, the incidents included operations delayed because the surgeon was not in place, the surgeon was double booked and the operation was cancelled. In one incident, when the delayed operation was not cancelled, the patient had ongoing general anaesthesia up to one hour while waiting for the surgeon. Reported incidents involving drug prescriptions included errors in prescribing drugs and incomplete or inadequate drug prescriptions.

Routines and guidelines

Routine and guideline disruptions were found in 60 reported incidents (27%). These were coded in two subcategories: drugs or materials (n = 37); noncompliance with guidelines (n = 23). The incidents involving drugs or materials were related to failure in routines for filling and refilling prescriptions, or failure in routines for refilling drugs or materials after being used. Failure in routines could result in drugs or materials not being replaced when needed. Stress and heavy workload were described as reasons for such failures. Other incidents involved noncompliance with guidelines related to the usage of devices and technologies. For example, devices and tools were mounted incorrectly after being used or batteries not being re-charged, according to guidelines. Consequently, failures in following guidelines were pointed out as a risk for the patient.

Patient care

A total of 47 incidents (21%) were related to patient care. The incidents were coded in five subcategories: drug managements (n = 16); patient identification errors (n = 14); adverse anaesthesia or surgical events (n = 9); language and interpreter (n = 5); information (n = 3). Incidents involving drug managements were reported as occurring in anaesthetics or preoperative medications. The patient has been given the wrong anaesthetic or the wrong dose of a medication. Patient identification errors were related to patients lacking an identifications band or a patient entering the operating room with the wrong medical record. Adverse anaesthesia or surgical events occurred during the operation. For instance, a dental injury occurred during intubation. Some incidents were related to language and interpreter. For example, an operation was cancelled because an interpreter was not present. In some incidents, the patient did not receive complete information and did not know about the operation.

The NAs work environment

This category contained 27 (12.3%) reported incidents in two subcategories: the physical work environment (n = 18); the psychosocial work environment (n = 9). Incidents in the physical work environment involved situations where the operating room was overly crowded. It was also reported that because the physical environment had been planned poorly, devices and technologies were in the way of NAs who were caring for the patient. The psychosocial work environment included reports on time pressure, stress and staffing. For example, the reported incidents included an overly tight schedule, NAs not having the time needed for safe patient care and staffing problems that caused stress.

Devices, materials and technologies

This category contained 24 incidents (11%) involving materials, devices and technologies, which were divided into five subcategories: devices (n = 12); materials (n = 7); false alarms (n = 3); computers (n = 2). These incidents involved devices in the operating room being out of order. Materials often were reported to have manufacturing defects or not to function effectively. Some incidents involved false alarms in the operating room, which disturbed the operating team and their work. Problems with computers were related to their slowness, or they involved the computer system.

The risk of harm in relation to the incidents

No risks of harm were reported in 36 (3%) of the 220 incidents. In the remaining reported incidents (n = 184), there was either a risk of harm or there had been an actual harm to patients or health care professionals. Of all incidents reported, 23 (10%) had harmed either patients or NAs (see Table 2). Relatively few incidents were reported as harming patients (n = 6), and more incidents were reported as harmful to NAs (n = 17). The majority (73%) of the reported incidents involved a risk of harm (n = 161) mainly to patients (n = 155). Few reported incidents involved a risk of harm to NAs (n = 6).

Table 2. Risks and harm to patients and NAs in the reported incidents. In total, 36 incidents were reported as no harm, 161 incidents were reported in patients and 23 in NAs.

	NO. OF INCIDENTS	% OF ALL INCIDENTS
NO HARM	36	16
RISK OF HARM TO PATIENTS	155	70
HARM TO PATIENTS	6	3
RISK OF HARM TO NA	6	3
HARM TO NA	17	8
TOTAL	220	100

Discussion

The most frequent category of reported incidents found in this study was communication and teamwork. Similarly, Gillespie et al. (2013) found that a risk of harm was associated with poor interprofessional communication and teamwork. Shortcomings in communication and teamwork were also found to be a major cause of critical incidents (Scharein & Trendelenburg, 2013). Insufficient communication has been recognised as not only a source of incidents but also a cause of patients’ suffering from health care (Berglund, Westin, Svanström, & Sundler, 2012). Thus, the communication competency of health care professionals is important and the findings suggest that improvements are needed. Patient safety and the care of patients in the operating room comprise an important part of patients’ disease trajectory and are highly dependent on effective and timely communication among health care professionals.

The second most frequent category was related to routines and guidelines that were not followed by health care professionals. This finding is in line with findings reported by Chakravarty (2013), which showed that errors were built into existing routines and devices, which was the case in incidents in the operating room reported in this study. It is a challenge to enhance patients’ safety and evidence-based care. Guidelines and routines are usually designed to support such care. In line with our study results, previous research presents interprofessional relationships and collaboration as one of several key issues in the implementation of evidence in practice (Rycroft-Malone et al., 2004). The implementation of evidence and fulfilling of guidelines could be more effective in organisations with well-functioning teams in the operating room. Moreover, crucial to improve safety according to guidelines is follow-up and should be initiated from i.e. project leader or head of department.

The findings of this study indicate that there were frequent reports near misses. Reviewing incidents may be beneficial to provide insights in near misses and areas for improvement. By utilizing such reports, organisations could prevent future incidents and thus learning from the reports (Leape, 2002). As already mentioned, the leadership is an important part of learning organisations not least in the implementation of strategies for prevention of severe events. Previous research points to benefits of reported incidents being linked to leadership and the levels of trust in managers (Vogus & Sutcliffe, 2007). However, there are a variety of reasons health care professionals do not make incident reports, e g. believing that there was no point in reporting near misses, lack of feedback and fear of disciplinary actions (Rashed & Hamdan, 2015). It has also been reported that nurses are more likely than physicians to report incidents (AbuAlRub, Al-Akour, & Alatari, 2015). The attitudes of and the communication between professionals are important parts of well-functioning teams (Gillespie et al., 2013). Incident reporting can positively affect patient safety in addition to changing health care professionals’ attitude and knowledge (Anderson et al. 2013). According to the findings, a more effective use of incident report and follow up system may be critical for high functioning teams and for the improvement of patient safety in the operating room.

To the best of our knowledge, this study is the first to describe incidents that occurred in operating rooms and reported voluntarily by NAs. Interestingly, the findings did not show an increase in the number of reported incidents related to unplanned and acute situations over time. The reported incidents mainly occurred on weekdays; this distribution followed the number of patients who were scheduled for surgery and the majority of work of the NAs being weekdays. Fewer incident reports were found on not-scheduled time, e.g. nights, than weekdays. This may be a result of fewer actual incidents. Alternatively, in acute situations with stress and greater workload resulting in challenges to patient safety, incidents may be under reported due to time constraints or other factors.

The reported incidents analysed in this study may not include all risks to patients at the actual unit where the study was conducted. According to previous research incidents may be strongly underreported, as found when comparing reports by professionals with those reported by observers (Capuzzo et al., 2005). The rate of incidents reported by health care professionals was less than half of those reported by observers, which suggests that the number of reported incidents may be fewer than the actual number of such events. However, the severity level of reported incidents highly agrees with the health care professional’s ratings and the observer’s ratings (Capuzzo et al., 2005). Even though the reporting of incidents is known to be underreported, the reports are even more important in stressing the issueof near misses and events. It may not be preferable to decrease the number of reported incidents, and decreased reporting might lead to risks not being identified as well as an increase in the number of actual harms to patients and professionals. Interestingly, the results show that nurses were more efficient in preventing harm to the patients than to themselves. To what extent NA contribute to safety in this setting compared to nurses in other settings would be interesting to investigate e.g. comparing pattern of environment or personal resources.

Limitations

A limitation of this study is that it cannot be considered to represent all incidents that occurred in the study setting. In addition, some incidents may have been underreported. Moreover, the study covered a specific region in Sweden and a group of NAs at a middle-sized hospital, which limits the generalizability of the findings. However, the findings of this study provided valuable knowledge about possible risks for and potential harm to patients and professionals.

The trustworthiness of research can be based on Guba and Lincoln’s (1989) four criteria: credibility, dependability, confirmability and transferability. In this study, in order for the reader to agree with and understand the findings, the methodology and procedures were presented as thoroughly as possible. The content analysis produced both qualitative and quantitative results, which were used to answer the research questions. According to Morgan (1993), this approach has been criticized and abandoned because it is not sufficiently qualitative or quantitative. Consequently the value of the method has been questioned. However, the systematic coding and counting used in this study were useful in achieving the study’s aims. To ensure clarity, examples were given to illustrate the content of the categories and subcategories. Finally, the findings provided knowledge about the incidents reported by NAs in the operating room, which could be transferable to other settings.

Conclusion

The findings of this study reveal communication and interprofessional teamwork as the two most common areas for PSRS, and suggest that strategies are needed to improve these areas. Future intervention studies are needed to improve such competencies and skills. Interventions are a key activity in promoting safe patient care (Reeves, Clark, Lawton, Ream, & Ross, 2017). Moreover, the adherence to guidelines and routines could improve patient safety and avoid future incidents. Thus, interprofessional interventions combining education and practice activities are needed (Reeves et al., 2017). The findings indicate that PSRS could be effective in preventing both patients and professionals from being harmed. Even though many of the incidents analysed in this study were reported for risks to patients or NAs, some incidents were reported as harmful. However, the incidents of harm were mainly related to NAs and their work environment. These findings indicate that the NAs were more efficient in preventing harm to patients than to themselves. Consequently, increased attention should be paid to the work environment of NAs and other health care professionals in this setting in order to prevent professionals from being harmed.

Declaration of Interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.