The effect of team training on intra-operative error frequency

Introduction

Adverse events and errors complicate around 10% of hospital admissions. Many adverse events occur in the operating theatre and they are associated with negative outcomes. The primary aim of this observational study was to assess the impact of a team-based educational programme on error frequency during vascular surgical procedures.

Methods

A programme of team training was developed based upon interviews with staff familiar with such training, a needs analysis and a review of current evidence. Vascular surgery operations were observed real-time and errors

were recorded using a validated tool. Operative parameters and clinical outcome data were recorded prospectively. Team training commenced during the period of observation and the curriculum was reactive to observed adverse events. Questionnaires about safety culture and peri-operative data were compared before and after the introduction of training.

Results

A total of 110 procedures (71 aortic, 29 lower limb and 10 carotid operations) were observed over 360 hours and 36 minutes. During the pre-intervention period (13/11/2017 to 18/04/2018), the median error frequencies were 13.5

per aortic case, 12.0 per lower limb case and 5.0 per carotid case. There were five major errors resulting in direct harm to patients. Equipment issues were the commonest source of error. Harm-causing errors most commonly resulted from adverse patient anatomy or physiology.

Following the introduction of the team training intervention (25/04/2018 to 04/12/2018) the median error frequency was 11.0 per aortic case, 16.0 per lower limb case and 8.0 per carotid case. There were four major errors resulting in harm. The reduction in error frequency for aortic surgery was significant (p=0.027). There was also a significant reduction in time lost to delays (19.0 vs 11.5 minutes per case; p=0.006) in this group. The differences in error frequencies for lower limb and carotid procedures were not significant. There were no differences in clinical outcomes or costs.

Conclusion

Multi-disciplinary team training reduces intra-operative errors and procedural delays during aortic surgery.