Abstract

Background: Patient safety is one of the greatest challenges in healthcare. In the operating room errors are
frequent and often consequential. This article describes an approach to a successful implementation of a patient
safety program in the operating room, focussing on latent risk factors that influence patient safety. We
performed an intervention to improve these latent risk factors (LRFs) and increase awareness of patient safety
issues amongst OR staff.
Methods: Latent risk factors were studied using a validated questionnaire applied to the OR staff before and
after an intervention. A pre-test/post-test control group design with repeated measures was used to evaluate the
effects of the interventions. The staff from one operating room of an university hospital acted as the intervention
group. Controls consisted of the staff of the operating room in another university hospital. The outcomes were
the changes in LRF scores, perceived incident rate, and changes in incident reports between pre- and postintervention.
Results: Based on pre-test scores and participants key concerns about organizational factors affecting patient
safety in their department the intervention focused on the following LRFs: Material Resources, Training and
Staffing Recourses. After the intervention, the intervention operating room - compared to the control operating
room reported significantly fewer problems on Material Resources and Staffing Resources and a significantly
lower score on perceived incident rate. The contribution of technical factors to incident causation decreased
significantly in the intervention group after the intervention.
Conclusion: The change of state of latent risk factors can be measured using a patient safety questionnaire aimed
at these factors. The change of the relevant risk factors (Material and Staffing resources) concurred with a
decrease in perceived and reported incident rates in the relevant categories. We conclude that interventions
aimed at unfavourable latent risk factors detected by a questionnaire focussed at these factors may contribute to
the improvement of patient safety in the OR.

Abstrak
Latar Belakang: Keselamatan pasien merupakan salah satu tantangan terbesar dalam
kesehatan. Di ruang operasi kesalahan yang sering dan sering konsekuensial. Artikel ini
menjelaskan pendekatan untuk keberhasilan pelaksanaan program keselamatan pasien di
ruang operasi, berfokus pada faktor-faktor risiko laten yang mempengaruhi keselamatan
pasien. Kami melakukan intervensi untuk meningkatkan faktor-faktor risiko laten (LRFs) dan
meningkatkan kesadaran tentang isu-isu keselamatan pasien antara OR staf.

Metode: faktor risiko laten dipelajari menggunakan kuesioner divalidasi diterapkan kepada
staf OR sebelum dan sesudah intervensi. Sebuah kontrol group design pre-test/post-test
dengan tindakan berulang digunakan untuk mengevaluasi efek dari intervensi. Staf dari satu
ruang operasi sebuah rumah sakit universitas bertindak sebagai kelompok intervensi. Kontrol
terdiri dari staf dari ruang operasi di rumah sakit universitas lain. Hasil adalah perubahan
nilai LRF, tingkat insiden yang dirasakan, dan perubahan dalam laporan insiden antara pradan pasca-intervensi.

Hasil: Berdasarkan skor pre-test dan keprihatinan utama peserta tentang faktor-faktor yang
mempengaruhi organisasi keselamatan pasien di departemen mereka intervensi terfokus pada
LRFs berikut: Material Resources, Pelatihan dan Kepegawaian sumberdaya. Setelah
intervensi, ruang operasi intervensi - dibandingkan dengan ruang operasi kontrol - yang
dilaporkan secara signifikan lebih sedikit masalah pada Sumber Daya Material dan
Kepegawaian Sumber dan nilai secara signifikan lebih rendah pada tingkat insiden yang

dirasakan. Kontribusi faktor teknis insiden penyebab menurun secara signifikan pada
kelompok intervensi setelah intervensi.

Kesimpulan: Perubahan keadaan faktor risiko laten dapat diukur dengan menggunakan
kuesioner keselamatan pasien ditujukan untuk faktor-faktor ini. Perubahan faktor risiko yang
relevan (Material dan Staffing sumber daya) sependapat dengan penurunan tingkat insiden
yang dirasakan dan dilaporkan dalam kategori yang relevan. Kami menyimpulkan bahwa
intervensi yang bertujuan menguntungkan faktor risiko laten terdeteksi oleh kuesioner
difokuskan pada faktor-faktor ini dapat berkontribusi pada peningkatan keselamatan pasien di
OR.

Martie van Beuzekom, Fredrik Boer, Simone Akerboom and Patrick Hudson Patient safety in
the operating room: an intervention study on latent risk factors, BMC Surgery: 2012, 12(10)

AHA
Cooperation is a critical element of teamwork as well and captures the feelings, attitudes, and beliefs that
drive behavior. Attitudinal components began to be studied after several tragic aviation accidents were attributed to
teamwork failures. Recognizing that the lack of teamwork skills (previously considered nonessential) created severe
consequences, the aviation industry developed and implemented CRM (ie, cockpit or crew resource management)
programs to improve teamwork.89

The ample evidence that poor teamwork skills (communication, leadership, situational
awareness) contribute to errors and adverse outcomes16,17,2123,58,61,75 suggests that teamwork
training to improve nontechnical skills should reduce errors.164,185 After the Institute of Medicine
published To Err Is Human,7 the Institute studied the successful use of CRM to reduce error in
aviation and recommended that team-training programs be implemented in critical care areas of
medicine. Implementation of these recommendations has taken time; the CRM principles had to be
adapted for use in medicine, teamtraining methods had to be developed, and the results of team
training had to be evaluated. Nonetheless, recent reviews have found that CRM-type strategies
consistently increase desirable teamwork attitudes170 and improve teamwork practices and outcomes
(eg, complication rates).189 Team perceptions of and attitudes toward patient safety are correlated
with the quality of patient safety.185
An early report of the benefits of formal team training demonstrated a significant
improvement in the quality of emergency department team behaviors and a reduction in clinical error
rate from 31% to 4.4%.190 Halverson et al reported that a team-training curriculum, with 4 hours of
classroom work and in situ coaching, increased the use of preoperative briefings191 and reduced
communication errors by half.74 Dedicated training sessions significantly improved communication
composite scores in the OR.192
In a preintervention and postintervention observational study in vascular and general surgery,
Oxford researchers implemented CRM-based teamwork training (9 hours of didactic and interactive
teaching).45,46 Teamwork scores and teamwork climate scores improved, and technical and
procedural error rates were reduced.46 A national prospective study of the Veterans Administration
Medical Team Training program based on CRM principles193 showed an 18% reduction in annual
mortality.63 There was a dose-response relationship between Medical Team Training and mortality:
For every quarter (3 months) of the team-training program, a reduction of 0.5 deaths per 1000
operations was observed.63 Implementation of Medical Team Training program was also associated
with a reduction in wrong-site surgery194 and improved compliance with best practices.195
Another national team-training effort is TeamSTEPPS, an evidence-based, resource-rich,
government-sponsored program (http://teamstepps.ahrq.gov/).196 Although TeamSTEPPS has been
implemented in hundreds of facilities, few empiric studies have examined its impact on patient
outcome. One recent study verified that this program of team training significantly improved OR
teamwork and communication scores, reduced surgical mortality and morbidity, increased OR
efficiency, and improved patient satisfaction.164 However, many of the initial gains were lost within
12 months, which indicates that sustained improvement may be difficult to achieve.164 Few data exist
to define the components of effective team training. Training times range from a few hours197 to
several days,45,46,63 program content is variable, and sustaining improvement may be difficult.164
In one posttraining observational study, surgical teams that had undergone training were compliant
with only 60% of the safety practices included in the program.198 In another such study,
communication and team skills improved immediately but extinguished after months.197 However,
the calculated threat-to-outcome score improved immediately and remained significantly improved 3
months later.197 From the data available, it appears that teams should be trained as teams, not as
individuals196; that use of simulated scenarios is effective196; that both executive leadership and
nurse managers are critical to effective implementation199; and that repetition, continued coaching, or
both are required to strengthen and maintain benefits.197,198

Dari penelitian Wiener et al, elemen penting dari kerjasama adalah sikap, dan
keyakinan yang dapat mendorong perilaku. Komponen sikap mulai dipelajari setelah
beberapa kecelakaan penerbangan tragis yang dikaitkan dengan kegagalan kerja sama tim.
Menyadari bahwa kurangnya keterampilan kerja sama tim (sebelumnya dianggap "tidak
penting") menghasilkan konsekuensi yang buruk, industri penerbangan mengemembangkan
dan mengimplementasikan CRM (yaitu, Cockpit atau Crew Resource Management) program
untuk meningkatkan teamwork. (Wiener EL, Kanki BG, Helmreich RL. Cockpit Resource
Management. San Diego, CA: Academic Press; 1993)
Menurut penelitian Catchpole, bukti bahwa keterampilan kerja sama tim yang buruk
(komunikasi, kepemimpinan, kesadaran situasional) berkontribusi terhadap kesalahan dan
hasil yang merugikan ditunjukkan bahwa pelatihan kerja tim untuk meningkatkan
keterampilan nonteknis dapat mengurangi kesalahan. Setelah Institute of Medicine yang
diterbitkan "Err Is Human," Institusi ini mempelajari keberhasilan penggunaan CRM untuk
mengurangi kesalahan dalam penerbangan dan direkomendasikan bahwa program timtraining dilaksanakan di ranah kedokteran dan perawatan kritis. Pelaksanaan rekomendasi ini
telah dilakukan; prinsip-prinsip CRM harus disesuaikan untuk digunakan dalam obat-obatan,
metode teamtraining harus dikembangkan, dan hasil pelatihan tim harus dievaluasi. Namun,
ulasan terakhir telah menemukan bahwa CRM-jenis strategi secara konsisten meningkatkan
sikap kerja sama tim yang diinginkan dan meningkatkan praktek kerja tim dan hasil
(misalnya, menurunnya tingkat komplikasi). Persepsi Tim dan sikap terhadap keselamatan
pasien berkorelasi dengan kualitas keselamatan pasien.
(Catchpole K, Mishra A, Handa A, McCulloch P. Teamwork and error in the operating room:
analysis of skills and roles. Ann Surg. 2008;
247:699706.)
Sebuah laporan awal manfaat dari pelatihan tim resmi menunjukkan peningkatan yang
signifikan dalam kualitas perilaku tim gawat darurat dan pengurangan tingkat kesalahan klinis dari
31% menjadi 4,4%. Halverson et al melaporkan bahwa kurikulum tim-pelatihan, dengan 4 jam kerja
kelas dan dalam pembinaan situ, meningkat penggunaan briefings191 pra operasi dan kesalahan
komunikasi dikurangi setengahnya. Sesi pelatihan khusus secara signifikan meningkatkan komunikasi
skor komposit di OR.

(Halverson AL, Andersson JL, Anderson K, Lombardo J, Park CS, Rademaker AW,
Moorman DW. Surgical team training: the Northwestern Memorial Hospital experience. Arch
Surg. 2009;144:107112)
Dalam preintervention dan penelitian observasional postintervention dalam pembuluh darah dan
bedah umum, peneliti Oxford dilaksanakan pelatihan kerja tim CRM berbasis (9 jam mengajar
didaktik dan interaktif). Skor Teamwork dan skor kerja sama tim membaik, dan tingkat kesalahan
teknis dan prosedural berkurang.

(Catchpole KR, Dale TJ, Hirst DG, Smith JP, Giddings TA. A multicenter trial of aviationstyle training for surgical teams. J Patient Saf. 2010;6:180186.)
(McCulloch P, Mishra A, Handa A, Dale T, Hirst G, Catchpole K. The effects of aviationstyle non-technical skills training on technical performance and outcome in the operating
theatre. Qual Saf Health Care. 2009;18:109115)
Sebuah penelitian prospektif nasional Program Administrasi Medical Team Training Veteran
berdasarkan prinsip CRM menunjukkan pengurangan 18% dalam kematian tahunan. Ada hubungan
dosis-respons antara Tim Medis Pelatihan dan mortalitas: Untuk setiap triwulan (3 bulan) dari
program tim-pelatihan, pengurangan 0,5 kematian per 1000 operasi diamati. Pelaksanaan program
Tim Medis Pelatihan juga dikaitkan dengan penurunan-situs operasi salah dan ditingkatkan sesuai

dengan praktik terbaik. (Paull DE, Mazzia LM, Wood SD, Theis MS, Robinson LD, Carney B,

Neily J, Mills PD, Bagian JP. Briefing guide study: preoperative briefing and postoperative
debriefing checklists in the Veterans Health Administration medical team training program.
Am J Surg. 2010;200:620623)

Upaya tim-pelatihan nasional lainnya adalah TeamSTEPPS, sebuah, kaya sumber daya, program yang
disponsori pemerintah (http://teamstepps.ahrq.gov/). Meskipun TeamSTEPPS telah
diimplementasikan dalam ratusan fasilitas, beberapa studi empiris telah meneliti dampaknya
terhadap hasil pasien. Salah satu studi baru diverifikasi bahwa program pelatihan ini meningkatkan
kerjasama tim dan skor komunikasi secara signifikan di OR, mengurangi mortalitas dan morbiditas
bedah, meningkat OR efisiensi, dan meningkatkan kepuasan pasien. (Armour Forse R, Bramble

JD, McQuillan R. Team training can improve operating room performance. Surgery.
2011;150:771778.)
Ada beberapa hal untuk menentukan komponen pelatihan tim yang efektif. Kali pelatihan berkisar
dari beberapa jam sampai beberapa hari isi program adalah variabel, dan mempertahankan
perbaikan mungkin sulit. Dalam satu posttraining penelitian observasional, tim bedah yang telah
menjalani pelatihan yang sesuai dengan hanya 60% dari praktek-praktek keselamatan yang
disertakan dalam program ini. Dalam studi lain seperti, komunikasi dan keterampilan tim membaik
segera dipadamkan tetapi setelah berbulan-bulan. Namun, dihitung ancaman-to-hasil skor membaik
segera dan tetap meningkat secara signifikan 3 bulan kemudian. Dari data yang ada, tampak bahwa
tim harus dilatih sebagai tim, bukan sebagai individu; bahwa penggunaan skenario simulasi yang
efektif; bahwa kedua kepemimpinan eksekutif dan manajer perawat sangat penting untuk
pelaksanaan yang efektif; dan bahwa pengulangan, lanjutan pelatihan, atau keduanya yang
diperlukan untuk memperkuat dan mempertahankan manfaat. (Robinson LD, Paull DE, Mazzia

LM, Falzetta L, Hay J, Neily J, Mills PD, Carney B, Bagian JP. The role of the operating
room nurse manager in the successful implementation of preoperative briefings and
postoperative debriefings in the VHA Medical Team Training Program. J Perianesth Nurs.
2010;25:302306.)

Menurut Rahmawati dalam penelitian Ika et al, faktor-faktor yang mempengaruhi

budaya keselamtan pasien diantaranya dapat dilihat dari tingkat manajemen dan tingkat
organisasi. Tingkat manajemnen meliputi persepsi manajemen tentang keselamatan pasien
dan keterlibatan manajemen dalam keselamatan pasien, sedangkan tingkat organisasi meliputi
kepemimpinan transformasional, SDM, kepemimpinan komite keselamtan pasien,
kepemimpinan pengawas safety, kejelasan dan keteraturan penempatan kerja dan audit
proses.
Ika FB, Syahrir AP, Noer BN. Gambaran Budaya Keselamatan Pasien Di Rumah Sakit
Universitas Hasanuddin. 2013