Journal of the American College of Surgeons
Volume 204, Issue 2 , Pages 236-243 , February 2007

Operating Room Briefings and Wrong-Site Surgery

  • Martin A. Makary, MD, MPH

      Affiliations

    • Department of Surgery, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD
    • Johns Hopkins University School of Medicine, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD
    • Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD
    • Center for Surgical Outcomes Research, Johns Hopkins Medical Institutions, Baltimore, MD
    • Corresponding Author InformationCorrespondence address: Martin A Makary, MD, MPH, Johns Hopkins University School of Medicine, Johns Hopkins Medical Institutions, 600 N Wolfe St, Carnegie 683, Baltimore, MD 21224.
    • ,
  • Arnab Mukherjee, BA

      Affiliations

    • Center for Surgical Outcomes Research, Johns Hopkins Medical Institutions, Baltimore, MD
    • Johns Hopkins Quality and Safety Research Group, Johns Hopkins Medical Institutions, Baltimore, MD
    • Yale University School of Medicine, Yale University School of Management, New Haven, CT
    • ,
  • J. Bryan Sexton, PhD

      Affiliations

    • Department of Anesthesiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD
    • Center for Surgical Outcomes Research, Johns Hopkins Medical Institutions, Baltimore, MD
    • ,
  • Dora Syin, BS

      Affiliations

    • Johns Hopkins University School of Medicine, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD
    • Johns Hopkins Quality and Safety Research Group, Johns Hopkins Medical Institutions, Baltimore, MD
    • ,
  • Emmanuelle Goodrich, MPH

      Affiliations

    • Johns Hopkins University School of Medicine, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD
    • ,
  • Emily Hartmann, MSS

      Affiliations

    • Georgetown University School of Medicine, Washington, DC.
    • ,
  • Lisa Rowen, RN, DScN

      Affiliations

    • Department of Nursing, Johns Hopkins University School of Nursing, Johns Hopkins Medical Institutions, Baltimore, MD
    • ,
  • Drew C. Behrens

      Affiliations

    • Johns Hopkins Quality and Safety Research Group, Johns Hopkins Medical Institutions, Baltimore, MD
    • Columbia University, New York, NY
    • ,
  • Michael Marohn, DO, FACS

      Affiliations

    • Department of Surgery, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD
    • Johns Hopkins University School of Medicine, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD
    • ,
  • Peter J. Pronovost, MD, PhD

      Affiliations

    • Department of Surgery, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD
    • Department of Anesthesiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD
    • Johns Hopkins University School of Medicine, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD
    • Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD
    • Department of Nursing, Johns Hopkins University School of Nursing, Johns Hopkins Medical Institutions, Baltimore, MD
    • Johns Hopkins Quality and Safety Research Group, Johns Hopkins Medical Institutions, Baltimore, MD

Received 8 August 2006 ,Revised 4 October 2006 ,Accepted 18 October 2006.

References 

  1. In:  Kohn L,  Corrigan J,  Donaldson M editor. To err is human: building a safer health systemInstitute of Medicine. Washington, DC: National Academy Press; 1999;
  2. Institute of Medicine. Committee on Quality of Health Care in AmericaCrossing the quality chasm: a new health care system for the 21st century. Washington, DC: National Academy Press; 2001;
  3. Joint Commission on Accreditation of Healthcare Organizations. Sentinel events: evaluating cause and planning improvement. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 1998;
  4. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: An observational classification of recurrent types and effects. Qual Saf Health Care. 2004;13:330–334
  5. Saufl NM. Universal protocol for preventing wrong site, wrong procedure, wrong person surgery. J Perianesth Nurs. 2004;19:348–351
  6. Makary MA, Sexton JB, Freischlag JA, et al. Patient safety in surgery. Ann Surg. 2006;243:628–632discussion 632–635
  7. Makary MA, Sexton JB, Freischlag JA, et al. Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder. J Am Coll Surg. 2006;202:746–752
  8. Sexton JB, Makary MA, Tersigni AR, et al. Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel. Anesthesiology. 2006;105:877–884
  9. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: Cross sectional surveys. BMJ. 2000;320:745–749
  10. DeFontes J, Surbida S. Preoperative safety briefing project. Permanente J. 2004;8:21–27
  11. Makary MA, Holzmueller CG, Thompson D, et al. Operating room briefings: working on the same page. Jt Comm J Qual Patient Saf. 2006;32:351–355
  12. Lingard L, Reznick R, DeVito I, Espin S. Forming professional identities on the health care team: Discursive constructions of the “other” in the operating room. Med Educ. 2002;36:728–734
  13. Dwyer K. Surgery-related claims and the systems involved. J Med Pract Manage. 2003;18:332–336
  14. Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Incidence, patterns, and prevention of wrong-site surgery. Arch Surg. 2006;141:353–357discussion 357–358
  15. Vincent C, Moorthy K, Sarker SK, et al. Systems approaches to surgical quality and safety: From concept to measurement. Ann Surg. 2004;239:475–482
  16. Klein KJ, Kozlowski SWJ. From micro to meso: Critical steps in conceptualizing and conducting multilevel research. Organizational Research Methods. 2000;3:211–236
  17. Sexton JB, Holzmueller CG, Pronovost PJ, et al. Variation in caregiver perceptions of teamwork climate in labor and delivery units. J Perinatol. 2006;26:463–470
  18. Sexton JB, Klinect JR. The link between safety attitudes and observed performance in flight operations. Columbus, OH: Ohio State University; 2001;(conference proceedings)
  19. Helmreich RL. On error management: lessons from aviation. BMJ. 2000;320:781–785
  20. Sexton J, Thomas EJ, Helmreich RL. Error, stress and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000;320:745–749
  21. Sexton J, Helmreich R, Williams R. The Flight Management Attitudes Safety Survey (FMASS). Research Project Technical Report 01–01. Austin, TX: University of Texas; 2001;
  22. Helmreich R, Foushee H, Benson R, et al. Cockpit resource management: exploring the attitude-performance linkage. Aviat Space Environ Med. 1986;57:1198–1200

 Competing Interests Declared: None.

PII: S1072-7515(06)01585-7

doi: 10.1016/j.jamcollsurg.2006.10.018

Journal of the American College of Surgeons
Volume 204, Issue 2 , Pages 236-243 , February 2007

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