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Pilot Testing of a Model for Insurer-Driven, Large-Scale Multicenter Simulation Training for Operating Room Teams

Arriaga, Alexander F. MD, MPH, ScD*,†,‡,§,¶; Gawande, Atul A. MD, MPH*,‡,§,¶; Raemer, Daniel B. PhD‖,**; Jones, Daniel B. MD††,‡‡; Smink, Douglas S. MD, MPH*,¶,§§; Weinstock, Peter MD, PhD¶¶,‖‖; Dwyer, Kathy MS, NP***; Lipsitz, Stuart R. ScD§,¶,†††; Peyre, Sarah EdD‡‡‡; Pawlowski, John B. MD, PhD‡‡,§§§; Muret-Wagstaff, Sharon PhD‡‡,§§§; Gee, Denise MD**,¶¶¶; Gordon, James A. MD, MPA‖‖‖,****; Cooper, Jeffrey B. PhD‖,**; Berry, William R. MD, MPH, MPA‡,§,¶; for the Harvard Surgical Safety Collaborative

Annals of Surgery:
doi: 10.1097/SLA.0000000000000342

Objective: To test the feasibility of implementing a standardized teamwork training program with full operating room teams in multiple institutions, driven by malpractice insurer support and incentives.

Background: Failures in intraoperative teamwork are among the leading causes of preventable patient injury and death in surgical patients. Teamwork training, particularly using simulation, can be an effective intervention but is difficult to scale.

Methods: A malpractice insurer convened a collaborative with 4 Harvard-affiliated simulation programs to develop a standardized operating room teamwork training curriculum, including principles of communication, assertiveness, and use of the World Health Organization Surgical Safety Checklist. Participant teams were compensated for lost operative time via malpractice premium discounts, continuing education credits, and compensation for lost wages. The course was delivered through a simulation program involving the management of intraoperative emergency scenarios. Participants were surveyed for their perceptions of the program and of its impact on clinical practice.

Results: A total of 221 active operating room staff members participated in the program. Each team contained at least 1 attending surgeon, 1 attending anesthesiologist, and 1 operating room nurse (mean size per team: 7 ± 2 participants). No study dates were cancelled because of lack of attendance. The survey response rate was 99% (218/221). Overall, the vast majority of participants found the scenarios realistic [94% (95% confidence interval: 90.9%, 97.2%)], appropriately challenging [95.4% (92.6%, 98.2%)], relevant to their practice [96.3% (93.8%, 98.8%)], and found the training would help them provide safer patient care [92.6% (89.1%, 96.1%)]. Surgeons reported their greatest personal deficit as communication skills. Operating room nurses and anesthesiologists reported a greater need than surgeons to work on personal assertiveness.

Conclusions: A standardized multicenter team training program involving full operative teams is feasible with high-fidelity simulation and modest compensation for lost time. The vast majority of the multidisciplinary participants believed the course to have had a meaningful impact on their approach to clinical practice.

In Brief

Failures in intraoperative teamwork are among the leading causes of preventable patient injury and death in surgical patients. High-fidelity medical simulation is feasible mechanism for the delivery of multicenter team training involving full operative teams.

Author Information

*Brigham and Women's Hospital, Department of Surgery, Boston, MA;

Brigham and Women's Hospital, Department of Anesthesiology, Pain, and Perioperative Medicine, Boston, MA;

Harvard School of Public Health, Department of Health Policy and Management, Boston, MA;

§Ariadne Labs, Boston, MA;

Brigham and Women's Hospital, Center for Surgery and Public Health, Boston MA;

Massachusetts General Hospital, Department of Anesthesia, Critical Care, and Pain Medicine, Boston, MA;

**The Center for Medical Simulation, Cambridge, MA;

††Beth Israel Deaconess Medical Center, Department of Surgery, Boston, MA;

‡‡Beth Israel Deaconess Medical Center, Carl J. Shapiro Simulation and Skills Center, Boston, MA;

§§Brigham and Women's Hospital, STRATUS Center for Medical Simulation, Boston, MA;

¶¶Boston Children's Hospital, Department of Anesthesia, Division of Critical Care Medicine, Boston, MA;

‖‖Boston Children's Hospital Simulator Program, Boston, MA;

***Risk Management Foundation of the Harvard Medical Institutions (CRICO/RMF), Cambridge, MA;

†††Brigham and Women's Hospital, Department of Medicine, Boston, MA;

‡‡‡University of Rochester, Department of Surgery, Rochester, NY;

§§§Beth Israel Deaconess Medical Center, Department of Anesthesia and Critical Care, Boston, MA;

¶¶¶Massachusetts General Hospital, Department of Surgery, Boston, MA;

‖‖‖Harvard Medical School, Gilbert Program in Medical Simulation, Boston, MA; and

****Massachusetts General Hospital, Department of Emergency Medicine, Boston, MA.

Reprints: William R. Berry, MD, MPH, MPA, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115. E-mail:

Disclosure: This study was supported by a grant from the Risk Management Foundation of the Harvard Medical Institutions (CRICO/RMF). Kathy Dwyer is a senior program director and William R. Berry is the associate medical director for CRICO/RMF. Jeffrey B. Cooper is the executive director for the Center for Medical Simulation, a nonprofit research and education organization that provides fee for service programs of the type described in this report. James A. Gordon is supported by contract W81XWH-09-2-001 under a cooperative agreement issued by the United States Army Medical Research Acquisition. No other disclosures relevant to the work were made by the remaining authors.

© 2014 by Lippincott Williams & Wilkins.