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Surfacing Safety Hazards Using

Standardized Operating Room Briefings


and Debriefings at a Large Regional
Medical Center
Authors: Bandari, Jathin; Schumacher, Kathy; Simon, Michelle; Cameron,
Danielle; Goeschel, Christine A.; Holzmueller, Christine G.; Makary, Martin A.; Welsh,
Robert J.; Berenholtz, Sean M.
Source: Joint Commission Journal on Quality and Patient Safety, Volume 38, Number 4,
April 2012 , pp. 154-160(7)
Publisher: Joint Commission Resources

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Abstract:
Background: Briefings and debriefings, previously shown to be a practical and feasible
strategy to improve interdisciplinary communication and teamwork in the operating room

(OR), was then assessed as a strategy to prospectively surface clinical and operational defects
in surgical careand thereby prevent patient harm.
Methods: A one-page, double-sided briefing and debriefing tool was used by surgical teams
during cases at the William Beaumont Hospital Royal Oak (Royal Oak, Michigan) campus to
surface clinical and operational defects during the study period (October 2006-May 2010).
Defects were coded into six categories (with each category stratified by briefing or debriefing
period) during the first six months, and refinement of coding resulted in expansion to 16
defect categories and no further stratification. A provider survey was used in January 2008 to
interview a sample of 40 caregivers regarding the perceived effectiveness of the tool in
surfacing defects.
Findings: The teams identified a total of 6,202 defectsan average of 141 defects per month
during the entire study period. Of 2,760 defects identified during the six-defect coding
period, 1,265 (46%) surfaced during briefings, and the remaining 1,495 (54%) during
debriefings. Equipment (48%) and communication (31%) issues were most prominent. Of
3,442 defects identified during the 16-defect coding period, the most common were Central
Processing Department (CPD) instrumentation (22%) and Communication/Safety (15%).
Overall, 70 (87%) of the 80 responses were in agreement that briefings were effective for
surfacing defects, as were 59 (76%) of the 78 responses for debriefings.
Conclusions: Briefings and debriefings were a practical and effective strategy to surface
potential surgical defects in the operating rooms of a large medical center.
Document Type: Research article
Publication date: 2012-04-01

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