Presentation
PS4 - Characterizing Physical Layout Safety Threats and Their Outcomes in Operating Rooms (ORs) Across Four Hospitals: Analysis Using OR Black Box Recordings
SessionPoster Session 2
DescriptionBackground and Rationale:
Suboptimal physical layouts in Operating Rooms (ORs) significantly contribute to disruptions in clinical workflows, which often precede surgical errors. These disruptions can range from minor incidents, such as a nurse bumping their head on an overhead light, to more serious events, like a surgeon twisting their ankle on a poorly placed step stool. These disruptions are a type of “safety threat” (ST) which can accumulate and increase the potential for errors and patient harm.
Poor physical layouts also contribute to occupational injuries in the hospital industry, costing the U.S. over $190 billion annually due to lost productivity. According to the US Bureau of Labor Statistics, the Health Care and Social Assistance sector recorded 5,623,000 occupational injury cases in 2015, ranking first among other sectors. Suboptimal physical layouts may contribute to these injuries through physical injury such as falls, which can result in absences from work, impacting clinicians financially and psychologically. Further, suboptimal layouts predispose surgeons to musculoskeletal (MSK) injuries, especially for physically demanding surgical specialties such as orthopaedic surgeries. Up to 90% of surgeons in all subspecialties reported MSK pain while conducting surgical duties.
Human Factors (HF) researchers have studied how errors occur in ORs by analyzing recordings from the OR Black Box® (ORBB), a platform that captures audio and video of real surgeries from multiple angles. There are several HF analyses of surgeries using the Systems Engineering Initiative for Patient Safety (SEIPS) model, looking for threats to patient safety in six system components: Person(s), Organization, Tools & Technology, Tasks, and Internal Environment. To date, these studies typically identify more person-related safety threats (STs) than physical layout STs. However, patient safety literature emphasizes that system changes (e.g., environment redesign) is more effective than attempting to change people (e.g., policy changes and training initiatives). Therefore, despite their lower frequency, a deeper understanding of how OR layouts contribute to safety threats is important. Further, it is possible that some physical layout issues may be resolvable simply by observing which hospitals have low occurrences of them; cross-institutional comparisons of ORBB recordings may help identify solutions that are transferable to other hospitals. For instance, advancements like wireless data transfer could eliminate the need for monitoring cables, thereby reducing the risk of personnel slips and falls.
There has been limited research on the comparative frequency of physical layout STs across different hospitals, as well as qualitative details of these layout issues. Further, these issues will persist in the design of new ORs unless they are systematically addressed. To this end, we are conducting an HF analysis of OR Black Box videos to identify and classify STs related to the physical layout across four hospitals to characterize potential improvements to physical layouts in ORs more generally.
Study objectives:
The objectives of the study are:
1) To identify the type and frequency of safety threats (STs) due to suboptimal OR physical layout through analysis of recorded surgeries from 4 hospitals.
2) To identify the institution-specific features that lead to increased or decreased prevalence of physical layout safety threats compared to other hospitals.
Methods:
We describe an exploratory observational study that analyzes video recordings captured by the OR Black Box® (Surgical Safety Technologies Inc., Toronto, Canada). This device collects and synchronizes multiple sources of audio-visual data from the OR. Observational data collected from the OR Black Box® originates from ORs at two large Canadian academic hospitals (Hospitals 1 and 2), one large American academic hospital (Hospital 3), and one large Canadian community hospital (Hospital 4). Surgical specialties captured in the data include: general, gynecological, and orthopedic surgery. Surgeries can be open or minimally invasive.
A team of HF specialists independently review surgical videos and manually transcribe observed physical layout STs. These events are then reviewed independently by at least two HF specialists and are coded with one primary outcome and one primary cause (determined inductively); conflicts are resolved by consensus. Categories of primary cause and primary outcome are determined inductively.
Preliminary Results:
As of September 30, 2024, 100 surgical cases have been coded ((number of cases per hospital; nhospital number): n1 = 28, n2 = 25, n3 = 32, n4 = 15). Data collection is ongoing at hospital 2 and 4; a further 20 cases is expected in total. At this time, 147 physical layout STs have been identified, the list and number of observed primary outcomes and causes are listed below. All included examples are taken from real events.
Primary Outcomes:
• Poor Posture (n = 31, e.g., a surgical resident has to slouch to view a laparoscopic monitor placed far below his height)
• Staff Injury (n = 20, e.g., a surgeon twists their ankle on a poorly placed step stool)
• Sterility Compromised (n = 6, e.g., a circulator who squeezes between an x-ray machine and scrub table accidentally bumps into equipment on the scrub table)
• Other (n = 25, e.g., a forced air warmer placed under the foot of the OR table is crushed when the surgeon asks for reverse Trendelenburg)
• Close Call (n = 20, e.g., an anesthesiologist is caught between the OR table and the stretcher as the team tries to turn the OR table. The surgical resident alerts the team to stop before the table squeezes the anesthesiologist)
• No Consequence (n = 45, i.e., a number of equipment are in the way as the patient is wheeled into OR)
Primary Causes:
• Suboptimal Equipment Placement (n = 105, e.g., laparoscopic monitor is placed far above eye level). This theme is subcategorized by the equipment that was poorly placed)
o IV/Wiring (n = 20)
o Monitor (n = 18)
o Scrub Table (n = 17)
o Step Stool (n = 8)
o Overhead Lights (n = 7)
o OR Table (n = 6)
o Other (n = 29)
• OR Design (n = 22, e.g., a frequently accessed storage room that’s only accessible through one OR)
• Floor Condition (n = 14, e.g., a pool of antiseptic on the floor is a slipping hazard)
• Staff Crowding (n = 6, e.g., a large number of staff members working in a small area can lead to collisions that drop instruments or impede teamwork)
Analysis to identify patterns of specialty-specific STs, institution-specific STs, and connections between primary causes and primary outcomes are ongoing.
Discussion:
Our preliminary analysis reveals that equipment placement was responsible for approximately 71% of physical layout safety threats (STs). Common issues, such as wires lying on the floor causing trip hazards or overhead lights positioned too low leading to blunt trauma, are well-documented in the literature as easily addressable workflow disruptions.
Poor posture among clinicians, due to suboptimal equipment placement, was the most frequently reported outcome, accounting for 21% of cases. Staff injuries, including falls and collisions with equipment, was the second most prevalent contributing to 13% of outcomes, further supporting existing research highlighting the prevalence of poor posture and staff injuries in surgical environments.
Our findings also show differences in layout safety threats based on surgical specialty and institution. For instance, orthopedic surgeries, which require X-rays and additional staff, often experience overcrowding in the OR. In Site 3, which has comparatively large ORs and a greater amount of equipment, we noticed more communication difficulties arising from the increased physical distance between staff members. These inter-institutional differences highlight the value of contrasting the type and frequency of physical layout safety threats across multiple hospitals to understand why and how some OR layouts are associated with more safety threats, and generates potential for sharing of best practices.
Suboptimal physical layouts in Operating Rooms (ORs) significantly contribute to disruptions in clinical workflows, which often precede surgical errors. These disruptions can range from minor incidents, such as a nurse bumping their head on an overhead light, to more serious events, like a surgeon twisting their ankle on a poorly placed step stool. These disruptions are a type of “safety threat” (ST) which can accumulate and increase the potential for errors and patient harm.
Poor physical layouts also contribute to occupational injuries in the hospital industry, costing the U.S. over $190 billion annually due to lost productivity. According to the US Bureau of Labor Statistics, the Health Care and Social Assistance sector recorded 5,623,000 occupational injury cases in 2015, ranking first among other sectors. Suboptimal physical layouts may contribute to these injuries through physical injury such as falls, which can result in absences from work, impacting clinicians financially and psychologically. Further, suboptimal layouts predispose surgeons to musculoskeletal (MSK) injuries, especially for physically demanding surgical specialties such as orthopaedic surgeries. Up to 90% of surgeons in all subspecialties reported MSK pain while conducting surgical duties.
Human Factors (HF) researchers have studied how errors occur in ORs by analyzing recordings from the OR Black Box® (ORBB), a platform that captures audio and video of real surgeries from multiple angles. There are several HF analyses of surgeries using the Systems Engineering Initiative for Patient Safety (SEIPS) model, looking for threats to patient safety in six system components: Person(s), Organization, Tools & Technology, Tasks, and Internal Environment. To date, these studies typically identify more person-related safety threats (STs) than physical layout STs. However, patient safety literature emphasizes that system changes (e.g., environment redesign) is more effective than attempting to change people (e.g., policy changes and training initiatives). Therefore, despite their lower frequency, a deeper understanding of how OR layouts contribute to safety threats is important. Further, it is possible that some physical layout issues may be resolvable simply by observing which hospitals have low occurrences of them; cross-institutional comparisons of ORBB recordings may help identify solutions that are transferable to other hospitals. For instance, advancements like wireless data transfer could eliminate the need for monitoring cables, thereby reducing the risk of personnel slips and falls.
There has been limited research on the comparative frequency of physical layout STs across different hospitals, as well as qualitative details of these layout issues. Further, these issues will persist in the design of new ORs unless they are systematically addressed. To this end, we are conducting an HF analysis of OR Black Box videos to identify and classify STs related to the physical layout across four hospitals to characterize potential improvements to physical layouts in ORs more generally.
Study objectives:
The objectives of the study are:
1) To identify the type and frequency of safety threats (STs) due to suboptimal OR physical layout through analysis of recorded surgeries from 4 hospitals.
2) To identify the institution-specific features that lead to increased or decreased prevalence of physical layout safety threats compared to other hospitals.
Methods:
We describe an exploratory observational study that analyzes video recordings captured by the OR Black Box® (Surgical Safety Technologies Inc., Toronto, Canada). This device collects and synchronizes multiple sources of audio-visual data from the OR. Observational data collected from the OR Black Box® originates from ORs at two large Canadian academic hospitals (Hospitals 1 and 2), one large American academic hospital (Hospital 3), and one large Canadian community hospital (Hospital 4). Surgical specialties captured in the data include: general, gynecological, and orthopedic surgery. Surgeries can be open or minimally invasive.
A team of HF specialists independently review surgical videos and manually transcribe observed physical layout STs. These events are then reviewed independently by at least two HF specialists and are coded with one primary outcome and one primary cause (determined inductively); conflicts are resolved by consensus. Categories of primary cause and primary outcome are determined inductively.
Preliminary Results:
As of September 30, 2024, 100 surgical cases have been coded ((number of cases per hospital; nhospital number): n1 = 28, n2 = 25, n3 = 32, n4 = 15). Data collection is ongoing at hospital 2 and 4; a further 20 cases is expected in total. At this time, 147 physical layout STs have been identified, the list and number of observed primary outcomes and causes are listed below. All included examples are taken from real events.
Primary Outcomes:
• Poor Posture (n = 31, e.g., a surgical resident has to slouch to view a laparoscopic monitor placed far below his height)
• Staff Injury (n = 20, e.g., a surgeon twists their ankle on a poorly placed step stool)
• Sterility Compromised (n = 6, e.g., a circulator who squeezes between an x-ray machine and scrub table accidentally bumps into equipment on the scrub table)
• Other (n = 25, e.g., a forced air warmer placed under the foot of the OR table is crushed when the surgeon asks for reverse Trendelenburg)
• Close Call (n = 20, e.g., an anesthesiologist is caught between the OR table and the stretcher as the team tries to turn the OR table. The surgical resident alerts the team to stop before the table squeezes the anesthesiologist)
• No Consequence (n = 45, i.e., a number of equipment are in the way as the patient is wheeled into OR)
Primary Causes:
• Suboptimal Equipment Placement (n = 105, e.g., laparoscopic monitor is placed far above eye level). This theme is subcategorized by the equipment that was poorly placed)
o IV/Wiring (n = 20)
o Monitor (n = 18)
o Scrub Table (n = 17)
o Step Stool (n = 8)
o Overhead Lights (n = 7)
o OR Table (n = 6)
o Other (n = 29)
• OR Design (n = 22, e.g., a frequently accessed storage room that’s only accessible through one OR)
• Floor Condition (n = 14, e.g., a pool of antiseptic on the floor is a slipping hazard)
• Staff Crowding (n = 6, e.g., a large number of staff members working in a small area can lead to collisions that drop instruments or impede teamwork)
Analysis to identify patterns of specialty-specific STs, institution-specific STs, and connections between primary causes and primary outcomes are ongoing.
Discussion:
Our preliminary analysis reveals that equipment placement was responsible for approximately 71% of physical layout safety threats (STs). Common issues, such as wires lying on the floor causing trip hazards or overhead lights positioned too low leading to blunt trauma, are well-documented in the literature as easily addressable workflow disruptions.
Poor posture among clinicians, due to suboptimal equipment placement, was the most frequently reported outcome, accounting for 21% of cases. Staff injuries, including falls and collisions with equipment, was the second most prevalent contributing to 13% of outcomes, further supporting existing research highlighting the prevalence of poor posture and staff injuries in surgical environments.
Our findings also show differences in layout safety threats based on surgical specialty and institution. For instance, orthopedic surgeries, which require X-rays and additional staff, often experience overcrowding in the OR. In Site 3, which has comparatively large ORs and a greater amount of equipment, we noticed more communication difficulties arising from the increased physical distance between staff members. These inter-institutional differences highlight the value of contrasting the type and frequency of physical layout safety threats across multiple hospitals to understand why and how some OR layouts are associated with more safety threats, and generates potential for sharing of best practices.
Event Type
Poster Presentation
TimeTuesday, April 14:45pm - 6:15pm EDT
LocationFrontenac Foyer