Plastic surgeons need to be aware of new approaches-and vigilant about following basic techniques-for preventing errors and protecting patient safety in the operating room, according to a special article in the November issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

"As the importance of teamwork becomes more evident, clear communication skills preoperatively, intraoperatively and postoperatively become equally critical," write ASPS Member Surgeon Dr. Samuel O. Poore of University of Wisconsin and colleagues. In the first of two articles, they highlight some key preoperative steps for maximizing patient safety during plastic surgery procedures.

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Crew Resource Management-Preventing Errors Through Communication

Studies have shown that communication breakdowns are a major contributor to medical errors. Crew Resource Management (CRM)-an approach borrowed from aviation-is emerging as a means of improving safety in health care as well. Dr. Poore and colleagues write, "Since being widely introduced into the airline industry, CRM has been shown to improve performance, safety, communication, morale and decrease accidents related to crew error." Initial experience suggests that CRM can also improve safety in medical settings-including the operating room.

With the increasing push for CRM in health care, plastic surgeons need to be familiar with the techniques involved. One practical approach introduced at several institutions is briefing/debriefing protocols. This involves discussing the surgical case or procedure before and afterwards-creating a "shared mental model" that sets the tone among the surgical team.

An important part of CRM is that it provides a safe setting for all members of the surgical team-regardless of rank-to express opinions and voice concerns. In one study of cardiovascular surgery, "Team members felt the briefing/debriefing process promoted professionalism and improved communication," according to the authors.

Back to Basics-Positioning and Infection Control

Poor communication is the root cause of a major type of preventable surgical error: wrong-site surgery. One recent study estimated that there are between 1,300 and 2,700 cases of "wrong site and wrong person surgery"-or near-miss events-each year in the United States.

Plastic surgeons need to be aware of the recently introduced "universal protocol" for preventing wrong-site surgery. The protocol specifies routines for verifying the correct site, person, and operation before every surgical procedure-including marking the incision site while the surgeon is present and the patient is awake.

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Safety problems can also result from inadequate attention to basic preoperative tasks. Improper patient positioning can result in problems like nerve injuries and pressure sores. "This is especially true in plastic surgery, where unusual positioning may be required for adequate exposure," Dr. Poore and coauthors note. They discuss important factors to assess risk and prevent injuries when positioning the patient for surgery-including some risks associated with specific surgical positions.

The review addresses other essential steps in preparing for surgery, including preoperative scrubbing and preparation of the patient's skin. The authors review the evidence behind routine steps followed by surgeons and operating room personnel, including techniques and products for handwashing and the use of surgical gowns, gloves and masks.

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Attention to such basic routines-all too easily overlooked in busy surgical settings-are critical to making plastic surgery as safe as possible. "This article should stimulate all plastic surgeons to be vigilant in assessing their practice to improve patient safety," Dr. Poore and coauthors write. In a companion article, they address safety issues to be aware of in the intraoperative (during surgery) and postoperative periods.