Exposure to incivility hinders clinical performance in a simulated operative crisis.

BACKGROUND: Effective communication is critical for patient safety. One potential threat to communication in the operating room is incivility. Although examined in other industries, little has been done to examine how incivility impacts the ability to deliver safe care in a crisis. We therefore sought to determine how incivility influenced anaesthesiology resident performance during a standardised simulation scenario of occult haemorrhage. METHODS: This is a multicentre, prospective, randomised control trial from three academic centres. Anaesthesiology residents were randomly assigned to either a normal or 'rude' environment and subjected to a validated simulated operating room crisis. Technical and non-technical performance domains including vigilance, diagnosis, communication and patient management were graded on survey with Likert scales by blinded raters and compared between groups. RESULTS: 76 participants underwent randomisation with 67 encounters included for analysis (34 control, 33 intervention). Those exposed to incivility scored lower on every performance metric, including a binary measurement of overall performance with 91.2% (control) versus 63.6% (rude) obtaining a passing score (p=0.009). Binary logistic regression to predict this outcome was performed to assess impact of confounders. Only the presence of incivility reached statistical significance (OR 0.110, 95% CI 0.022 to 0.544, p=0.007). 65% of the rude group believed the surgical environment negatively impacted performance; however, self-reported performance assessment on a Likert scale was similar between groups (p=0.112). CONCLUSION: Although self-assessment scores were similar, incivility had a negative impact on performance. Multiple areas were impacted including vigilance, diagnosis, communication and patient management even though participants were not aware of these effects. It is imperative that these behaviours be eliminated from operating room culture and that interpersonal communication in high-stress environments be incorporated into medical training.

One-lung ventilation for surgical repair of thoracic aortic aneurysm.

Advances in the surgical approach to thoracic aortic aneurysm repairs have led to the increasing use of one-lung ventilation. Today's practice of cardiothoracic and vascular anesthesia requires a clear understanding of the techniques available for lung separation and the technical skills necessary to employ them. In this article, we discuss and evaluate the options for one-lung ventilation in thoracic aortic aneurysm repair with regard to preoperative, intraoperative, and postoperative management.

An unexpected needlestick injury.

Needle stick injuries occur at a significant rate. According to the National Institute for Occupational Safety and Health, there are approximately 600,000 to 800,000 needlestick and other percutaneous injuries every year among healthcare workers. Not only do the needlestick injuries put workers at risk for blood borne pathogens, but they cause a significant psychological and emotional burden for those involved. This is a report of an anesthesia resident who sustained a needlestick injury through the sterile drapes by a surgical resident.

Missed steps in the preanesthetic set-up.

BACKGROUND: Anesthesiologists accomplish many tasks rapidly during induction of an anesthetic. Key preparation for induction is needed to maximize patient safety. Given the intense environment of the operating room, preparatory steps may be missed either unintentionally or possibly even intentionally to save time. We conducted this study to determine the incidence of missed steps in the operating room immediately before induction. METHODS: In this study, 200 surgical procedures were randomly checked for missed steps before induction of anesthesia using a "Revised Preanesthetic Set-Up." Additionally, multiple other operating room/case variables were recorded to determine whether there was correlation between the missed steps and certain variables such as room case load and regional versus general anesthesia. RESULTS: Twenty-three missed steps were discovered. Manual resuscitation device availability and a working suction set-up were the most frequently missed steps. A higher percentage of missed steps was found in cases in which regional was the planned anesthesia technique, in rooms with higher case loads (≥5 cases scheduled), and in rooms that attending anesthesiologists completed the set-up. CONCLUSIONS: Missed steps do occur at a significant and measurable rate. Measures need to be taken to decrease the number of missed steps to improve patient safety.