The presentation discusses the importance of safety in operating rooms (OR), highlighting common errors that can occur, such as wrong patient or site surgeries, and emphasizing the need for a culture of safety. It draws parallels between the OR and airline cockpit environments, advocating for principles of crew resource management (CRM) to enhance communication, leadership, and teamwork. The conclusion underscores that an optimal safety system involves a collective approach, accountability, and a commitment to continuous improvement to ensure patient safety and operational efficiency.

1. OPERATING ROOM
SAFETY
DR. ANKIT MADHARIA
JUNIOR RESIDENT, DEPARTMENT OF ORTHOPAEDICS
LATA MANGESHKAR HOSPITAL, NAGPUR

2. Outline
Why talk about OR safety?
Do we have a problem?
Is there anywhere we can look for help?
Is there a “Culture of Safety”?

3. As surgeons, what do we want the
operating room to be?
Efficient
Easy access to schedule cases
Have the supplies and instruments we
need when we need them
Safe

4. Who’s safety are we talking about?
Surgicalteam
Surgeon
Nursing staff
Anaesthetist
Attendants
Patient’s
safety

5. How do we benefit from surgery that is
safe for our patients
Less morbidity and mortality
Improved quality of our work
Less liability
Greater efficiency

6. Operating Room Errors:
× Wrong patient
× Wrong operation
× Wrong site or side
× Unexpected intra-
operative death
× Intra-operative
complications
× Retained foreign
bodies
× Operating room fires
× Mishandling of
surgical specimens
× Patient injury due to
positioning or burns
× Medication errors
× Transfusion mishaps
× Injury to the
surgical team
members

7. When is our patient safe in the OR?
Never –
errors can and do occur !!
◦To Err is Human…..

8. Hazards in operating room
•Blood/body fluid exposures
from sharps
•Exposure to released
particulates
•Exposures to waste
anesthetic gases
•Possible exposures to
chemical cleaning agents
Slips/trips/fall hazards
•Exposures to lasers/ X-ray
Radiations
•Hitting heads on OR lights
•Electrical shock hazards
•Fires

9. Blood/Body Fluid Exposures
50% of our sharps injuries occur during use.
Procedures with the most sharps injuries:
Suturing
Blood sampling
Intradermal injections
Cutting (Scalpel injuries)
Inserting IV Lines

10. Blood/Body Fluid Exposures
50% of our sharps injuries occur after use.
Procedures with the most sharps injuries:
Withdrawing needle from patient
During clean up and disassembly
During disposal
Overfilled sharps container, Protruding needles
Needles left in dustbin, laundry, OT Table , on the floor

11. Blood/Body Fluid Exposures
What can we do to prevent these exposure
injuries?
Utilize safe zone during each surgical procedure
Account for all sharps used
Dispose off sharp in sharps container
immediately after use
When emptying suction canisters, always pour
carefully and wear eye/face protection
Use personal protective equipment(PPE)

12. Blood/Body Fluid Exposures
Should an exposure occur:
For face/ eye exposure: Rinse with water
for about 15 minutes
For needle-stick injuries:
Express blood from stick
 wash with soap and water or betadine.
 Spirit/sterillium NOT to be used.

13. Particulate releases
Some procedures in the OR generate particulates into
the air (i.e., from cauterizing blood vessels, using lasers)
These particulates can have viable organisms present
that can cause infections
Preventive actions:
Use suction close to point of generation
Wear tight fitting safety goggles
Wear N95 respirator

14. Waste Anaesthetic Gases
Releases of anaesthetic gases into an OT can result in loss
of small motor skills, slowing of reflexes, metal confusion,
tiredness
Action by the anaesthesiologist can minimize these
exposures:
Check all connections before use for leaks
Pack endotracheal tube to prevent leaks
Have equipment serviced/checked periodically

15. Slips/Trips/Falls
The walking surface of OT locations can be
slippery, causing an injury
Take the appropriate precautions
Wear slip resistant foot wear
Report water/fluids on floor for clean up
Have personnel place a “CAUTION – WET
FLOOR” sign on floor until cleaned

16. X-rays , Lasers
We must prepare the OT for use of X-Rays/ Lasers
 Place Lead aprons / lead thyroid shield at the entry
of OT to be used by everyone inside the OT
 Place the eye protection equipment at the entry of
OT if Laser is to be used,
 Verify that personnel entering the OT have
adequate protection on
 Keep the use of C-arm to the minimum

17. Head injuries
OT lights are adjustable. Sometimes they
may be in a position that can cause a head
injury.
Use these simple rules:
Keep light up, out of the way until needed
Once done using, move the light up, out of
the way

18. Electrical Shocks
Shocks are usually the result of faulty
equipment
Take the following actions:
Unplug power cords by holding the plug, never
pull the cord
Never operate equipment if the ground plug is
missing. Take the unit out of service for repairs
Prevent exposure of electrical equipment from
body fluids/ Other electrolytes inside the OT

19. Fire
In order to understand how fire extinguishers work, you first
need to know a little bit about fire.
Essentially, fire extinguishers put out fire by taking away one
or more elements of the fire triangle.

20. Pressure injuries to patient
Anaesthetised patient is prone to pressure injury
It can be prevented by:
Proper patient positioning
Adequate padding
Preventing generation of pressure points

21. Safety Success story
Commercial Airline Industry

22. Tenerife – the crash that changed the
airline industry
Deadliest crash in aviation history: 538 Fatalities
1977, Tenerife island, Canary islands
Collision of KLM Boeing 747 and Pan Am Boeing 747

23. Tenerife – the crash that changed the
airline industry
Cockpit KLM 747
•Captain Jacob van Zanten – A Star pilot
•Copilot- First officer
•Flight Engineer- Second officer
Dense fog, one runway
Pan Am 747 on runway, out of sight of KLM 747

24. Tenerife – the crash that changed the
airline industry
Captain Co-Pilot
Captain puts
KLM plane on
runway and is in
a rush to take
off

25. Tenerife – the crash that changed the
airline industry
Captain Co-Pilot
Wait, we do
not have
clearance yet!
With great hesitation

26. Tenerife – the crash that changed the
airline industry
Captain Co-Pilot
Air traffic
control
clearance given
but takeoff
clearance not
given and
captain begins
throttling up

27. Tenerife – the crash that changed the
airline industry
Captain Co-Pilot
Copilot rushes
to try and get
clearance,
communication
is poor with
tower but co-
pilot gives pilot
the OK to
takeoff.

28. Tenerife – the crash that changed the
airline industry
Captain Co-Pilot
Copilot focuses
on his duties to
assist the
captain and says
nothing

29. Tenerife – the crash that changed the
airline industry
Captain Co-Pilot
At 45 knots,
the very junior
flight engineer
speaks up
lightly and
says
Is he not clear
then, the Pan
Am
Flight engineer

30. Tenerife – the crash that changed the
airline industry
Captain Co-Pilot
At 45 knots,
the very junior
flight engineer
speaks up
lightly and
says
Is he not clear
then, the Pan
Am
Flight engineer
What? What?

31. Tenerife – the crash that changed the
airline industry
Captain Co-Pilot
At 80 knots,
the flight
engineer
repeats in a
soft voice
Is he not clear
then, the Pan
Am
Flight engineer

32. Tenerife – the crash that changed the
airline industry
Captain Co-Pilot
At 80 knots,
the flight
engineer
repeats in a
soft voice
Is he not clear
then, the Pan
Am
Flight engineer
What!

33. Tenerife – the crash that changed the
airline industry
At 112 knots, the
captain sees Pan Am
747 sideways on
runway and tries to
leapfrog over the
plane…..collision
occurs….538 fatalities

34. WHY?
Several factors
Myth: senior airline captains are failsafe ; avoiding
mistakes due to their experience, and wits.
Assumption - a person of such stature is presumed to be
perfect
Culture of the airline cockpit before Tenerife
Misunderstood words or phrases
Lack of communication

35. Response
1978 – NASA research indicates that majority of airline
disasters NOT due to pilots lack of technical skill or
mechanical failure BUT from errors associated with
breakdowns in:
Communication
Leadership
Teamwork

36. Response
Cockpit Resource Management (CRM) evolved:
oFocus on human and systems issues
oWork culture within cockpit gradually modified
oAll members of crew empowered to provide feedback,
opinion, ask questions, “hard stop”
oError management
oStandardized checklists, forcing functions and language of
cockpit communications

37. Another example: Comair flight 5191,
Attempted take off from wrong
runway resulting in crash
Crash Report:
◦“The flight crewmembers failed to
recognize that they were initiating
a take off on the wrong runway
because they did not crosscheck
and confirm the airplane’s position
on the runway before takeoff and
they were likely influenced by
confirmation bias.”

38. Another example: Comair flight 5191,
Attempted take off from wrong
runway resulting in crash
Crash Report:
◦“The flight crew’s noncompliance
with standard operating procedures,
including the captain’s abbreviated
taxi briefing and both pilots’ non-
pertinent conversation, most likely
created an atmosphere in the cockpit
that enabled the crew’s errors.”

39. THINK ABOUT THIS…
Technical excellence alone does not
always guarantee a positive outcome
Being a good leader and getting the
most from a team are not directly linked
to your technical expertise

40. The Impact of Crew Resource Management
(CRM) on the Commercial Airline Industry
Improved cockpit team interactions
Fewer errors
Better morale
Commercial flight more cost effective
Overall rate of airline incidents has declined
Commercial aviation is the safest form of transportation
on a per mile basis

41. Airline cockpit and the operating room

42. Airline cockpit and the operating room
Similarities:
High risk
Highly complex technical work
Intelligent motivated people
Teams
Differences:
Airline pilots have strict duty hours
Pilots avoid punishment if they
promptly report errors, surgeons fear
litigation and loss of registration
Airlines learned long ago that
certain weather conditions make a
safe landing unlikely….surgeon tend
to operate on anyone they want to !!

43. What makes an OR safer?
Less Errors

44. OR Safety Pyramid
Errors that cause
harm
Errors
Near misses
Process problems
These we all hear about
Our OR needs to have a
system to capture these
Our OR needs to
capture signals that tell
us we may have these

45. Errors depend on two kinds of failures:
An error of planning
An error of execution
“Slips, lapses and
mistakes”
- part of humanity
- exacerbated by
anxiety, fatigue and
fear

46. American college of Surgeons
- OR Safety and Crew Resource Management
(CRM)
Applying the aviation model to the operating room

47. Seven principles (CRM)
1. Command – one final decision maker who must be
willing to foster the team and accept responsibility
and accountability for their team’s actions.

48. Seven principles (CRM)
2. Leadership – defined by commanders willingness
to let team members exercise their rights and
responsibilities to ensure a safe and positive
outcome. Although there is only one commander
any member of a team can show leadership.
Surgeons who encourage teamwork are MORE
respected.

49. Seven principles (CRM)
3. Communication – teams that fail to communicate
are doomed to negative results and errors. Adverse
OR events often related to poor communication due
to factors such as steep hierarchies, stress and
cultural differences

50. Seven principles (CRM)
4. Situational awareness – an effective leader relies
on team to promote situational awareness through
effective communication about what is occurring.
“Why didn’t you tell me !”

51. Seven principles (CRM)
5. Workload management – organizing tasks such
that there is equitable distribution amongst team
members. “Plan the work and work the plan”

52. Seven principles (CRM)
6. Resource management – optimal use of all
information, data, assistance available to the team.
Ensuring the presence of needed resources.

53. Seven principles (CRM)
7. Decision making
Collaborative – discouraged in high performance teams
Unilateral – fast but is a problem if leader is not aware of
all information or makes incorrect decision
Consultative – most effective in high performance
teams. Leader must know when to stop gathering data.

54. WHO Guidelines for safe surgery

55. WHO Guidelines for safe surgery

56. What can we do to achieve a “Culture of
Safety” in our ORs
Commit to safety
Focus on safe operations
Recognize a high risk
situation
View safety as a system
responsibility with individual
accountability
 Surgeons provide
leadership
 Encourage teamwork
Collect data
OR quality and safety
committee

57. Conclusions
The airline industry has taught us that:
The most experienced, most skilled, most
dedicated, most charming pilot (surgeon) can make a
bad mistake.
Even the best pilot (surgeon) will not be able to
single handedly prevent all errors made in the cockpit
(Operating room)

58. Conclusions
An optimal error reduction (safety) system involves:
A team approach – you cannot do it alone
A fair and non-threatening workplace
Standardized approaches such as “Time out”
Rigorous and real time scrutiny of errors, close calls and near
misses
Don’t play the blame game - Hold individuals responsible for
recklessness and foster personal accountability BUT hold the
system responsible for errors.
A constant unrelenting desire to improve

59. Strive for a “Culture of Safety” in our ORs
It’s good for our patients
It will minimize OUR chance of getting into trouble
It will minimize the chance of someone else getting US
into trouble
It will make the OR a more efficient place for us to work

60. Thank you.