Review Question - QID 213977

A sponge was misplaced during a surgical procedure. While there are multiple factors that led to this event and surgical delay, the best course of action would be to institute OR wide training focusing on crew resource management.

Creating a culture of safety is essential in the fast-paced and stressful environment of the operating room (OR). A training modeled after aviation-derived crew resource management is a means to promote teamwork and patient safety within the surgical environment. Errors in the operating room are usually multi-factorial (i.e. case complexity, case stress, staff fatigue, shift changes, poor communication, fear, human factors) and as a result blaming and ignoring do not adequately prevent future occurrences and degrade the team mentality. However, by taking advantage of the highly trained and motivated individuals in the OR similar to aviation, crew resource management has been shown to reduce errors and improve safety by enhancing team dynamics and communication.

Zeltser and Nash discuss how training in team behavior, leadership, communication, and other factors could lead to reduced errors and improve patient safety. They discussed the adaptation of crew resource management within medicine and its effectiveness after adaptation. Finally, they discussed its future direction within medicine.

Hughes et al. looked at the implementation of crew resource management training. They scored communication and teamwork prior to the program's implementation and compared them to after implementation. They found that participants reported improved accuracy in medical command information, ED information during resuscitation, team leader identity, communication of plan, role assignment, and speaking up to protect patient safety. They concluded that crew resource management enhances team dynamics and communication and improves patient safety.

Wakeman and Langham reviewed crew resource management and its adaptation with the operating room and healthcare. They discussed how it has improved communication and morale for staff and reduce morbidity and mortality for patients. They concluded that crew resource management will continue to be implemented more and become a regular part of residency and medical training due to its effectiveness in facilitating a team approach and patient safety.

Incorrect Answers:
Answer 1: An isolated policy for sponges alone does not adequately address the multiple factors that led to this event.
Answer 2: An isolated policy change for shifts alone does not adequately address the multiple factors that led to this event.
Answer 3: While the sponge was found, ignoring the event does not help to prevent future events/errors.
Answer 4: Reprimanding individuals in this situation does not prevent future occurrences.