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Locating Errors Through Networked Surveillance: A Multimethod Approach to Peer Assessment, Hazard Identification, and
David A Thompson1, Jill A Marsteller, Peter J Pronovost
1From the *Johns Hopkins Medicine, Armstrong Institute for Patient Safety and Quality; †Johns Hopkins University School of Medicine, ‡School of Nursing, and §Bloomberg School of Public Health, Baltimore, ∥University of Michigan School of Medicine, Ann Arbor; and ¶Massachusetts General Hospital, Harvard University, Boston.
Objectives:
The objectives were to develop a scientifically sound and feasible peer-to-peer assessment model that allows health-care organizations to evaluate patient safety in cardiovascular operating rooms and to establish safety priorities for improvement.
Methods:
The locating errors through networked surveillance study was conducted to identify hazards in cardiac surgical care. A multidisciplinary team, composed of organizational sociology, organizational psychology, applied social psychology, clinical medicine, human factors engineering, and health services researchers, conducted the study. We used a transdisciplinary approach, which integrated the theories, concepts, and methods from each discipline, to develop comprehensive research methods. Multiple data collection was involved: focused literature review of cardiac surgery-related adverse events, retrospective analysis of cardiovascular events from a national database in the United Kingdom, and prospective peer assessment at 5 sites, involving survey assessments, structured interviews, direct observations, and contextual inquiries. A nominal group methodology, where one single group acts to problem solve and make decisions was used to review the data and develop a list of the top priority hazards.
Results:
The top 6 priority hazard themes were as follows: safety culture, teamwork and communication, infection prevention, transitions of care, failure to adhere to practices or policies, and operating room layout and equipment.
Conclusions:
We integrated the theories and methods of a diverse group of researchers to identify a broad range of hazards and good clinical practices within the cardiovascular surgical operating room. Our findings were the basis for a plan to prioritize improvements in cardiac surgical care. These study methods allowed for the comprehensive assessment of a high-risk clinical setting that may translate to other clinical settings.
