Patient safety in the operating room

INTRODUCTION — Safety refers to flawless execution of an appropriate plan. When the intended plan (best practice) is not executed because of errors or violations, adverse events may occur. Human errors and/or communication failures cause or contribute to most adverse events in health care settings [1]. In the United States, the Joint Commission has set patient safety goals for hospital accreditation [2].

This topic reviews patient safety in the operating room (OR), including general and specific approaches to reduce risks for various hazards. A separate topic reviews control of infectious disease transmission by aerosol, contact, droplet exposure, or needle stick injury in this setting. (See "Overview of infection control during anesthetic care".)

Patient safety in other hospital settings is discussed in separate topics:

●Labor and delivery settings – (See "Reducing adverse obstetric outcomes through safety sciences".)

●Inpatient wards – (See "Rapid response systems".)

TYPES OF HUMAN ERRORS — The science of safety is based on the premise that everyone makes errors that can cause adverse outcomes. More than half of perioperative adverse events have been shown to be due to preventable errors [3-5]. By definition, such errors are unintentional, involving a flawed plan to achieve an aim, or the failure to carry out a well-planned action as intended [6]. Communication failures, cognitive errors, or technical problems may be involved [3,5,7-10].

Communication-based errors — Communication failures are a leading root cause of serious adverse events that result in patient harm [11-21]. These include poor timing, wrong audience, missing or inaccurate content, or ineffective communication [14].

Structured communication is routinely used to avoid errors in high-risk industries (eg, nuclear power, aviation, military operations), and should be used in operating rooms (ORs), especially in crisis situations or during complex surgical cases [14,22-25]. Examples of structured communication include:

●Identification of the intended recipient by beginning a communication with the individual's name.

●Use of closed loop communication (ie, speak-back or call-back) by requiring the receiver to repeat the message as heard, after which the sender verifies accuracy.

●Use of NATO phonetic alphabet (eg, alpha, bravo, Charlie, to distinguish sound-alike words or patient names [eg, Vance versus Chance] and numbers [eg, "one one" for eleven since pronunciation of eleven sounds similar to seven]).

Other specific strategies to prevent or minimize communication errors include use of protocols for multiple standardized verifications of information, as discussed below. (See 'Timeouts, briefing, and debriefing' below and 'Handoffs' below.)

Cognitive errors — Action-based and decision-based errors can occur due to inherent cognitive processes [26,27]. Either errors of commission (implementing a wrong action or making a wrong plan) or omission (failing to execute all steps of the plan or excluding some data when making a diagnosis or coming to a conclusion) may be involved. Notably, many so-called cognitive errors are actually violations, whereby the clinician consciously deviates from a practice accepted to be optimal [6]. Such violations are generally not malevolent (the clinician does not intend harm) but may occur due to a necessary work-around (eg, failure to use a bar code scanner that is not working), perceived inconvenience, or an attempt to increase productivity (eg, not performing appropriate hand hygiene).

Cognitive processes may be categorized as fast System-I thinking (automatic, subconscious), or slow System-II thinking (deliberate, conscious reasoning (table 1), as described below (see 'Action-based errors' below and 'Decision-based errors' below) [28]. However, few events involve only one of these types of thinking because clinicians move effortlessly between the two [29].

Action-based errors — These are errors based on failure to correctly apply familiar skills and rules during familiar action sequences [6,28,30]. Contributing factors can be individual (eg, fatigue, illness, cognitive overload), environmental (eg, disruptive conversations, interruptions), or system vulnerabilities (eg, production pressure, inadequate tools).

Examples of action-based errors include skipping or repeating steps in a familiar action sequence [26], syringe or vial swap, using the wrong rule in a situation, or faulty pattern matching. Prevention of action-based errors involves a brief conscious effort to check that the planned action is the correct one and verify the expected outcome after the action (ie, stop, think, act, and reflect [STAR]).

Decision-based errors — Decision-based errors involve slow System-II thinking that is reflective, deductive, conscious, effortful, and logical [6,28,30]. Such errors occur when the presenting facts match no recognizable pattern, when no mental model fits the situation, or when the patient response to subconsciously driven interventions is unexpected [29]. Cognitive biases may lead to inadequate risk assessment, incorrect diagnosis, and/or incorrect choice of treatment [21,31]. An initial error can be compounded by persistence on an incorrect thought pathway. Decision-based errors are more insidious and difficult to identify and correct than action-based errors [21,32].

Prevention of decision-based errors involves improving awareness and insight into cognitive biases and considering alternative possibilities (table 2) [31]. Specific strategies include:

●Conscious contemporaneous review of thought processes for possible cognitive biases by the individual clinician, or consultation with team members (surgeon, another anesthesia clinician) who may not share the same cognitive bias or mental model.

●Use of cognitive aids to decrease reliance on raw memory particularly during emergencies. (See "Cognitive aids for perioperative emergencies".)

●Use of evidence-based best practices and/or simulation training to practice management of specific clinical scenarios. (See 'Institutional and systems approaches to safety improvement' below.)

Technical errors — Technical errors typically occur when the difficulty of the task exceeds the clinician's proficiency, or when the patient’s anatomy is abnormal and complex [3,7,8]. Specific strategies to prevent or minimize these errors include:

●Using technology for skill-based tasks (eg, ultrasound guidance for central line placement).

●Redundancy (eg, two-person checks, using ultrasound guidance, and transducing the Seldinger wire in a central vein prior to insertion of a much larger catheter). (See "Placement of jugular venous catheters", section on 'Dynamic ultrasound-guided access' and "Placement of jugular venous catheters", section on 'Venous confirmation'.)

●Seeking additional proficiency or expertise (eg, inviting a colleague to provide a "second pair of hands" if this might be beneficial).

APPROACHES TO RISK REDUCTION

Standardized machine and equipment checkouts

●Anesthesia machine checkout – During the anesthesia provider’s preparation of the operating room (OR), meticulous adherence to the standardized pre-use anesthesia machine checkout avoids most critical incidents related to misuse or failure of the anesthesia workstation (table 3). (See "Anesthesia machines: Prevention, diagnosis, and management of malfunctions", section on 'Standardized anesthesia machine checkout'.)

Preparation should include checking the function of advanced airway and anesthesia and monitoring equipment. (See "Airway management for induction of general anesthesia" and "Basic patient monitoring during anesthesia".)

●Other OR equipment – Various machines, monitors, and equipment used in the perioperative setting may cause harm due to inadequate training on the device, poor machine design or maintenance, or lack of availability when needed [33-36]. Standardizing the location and layout of emergency equipment (eg, the difficult airway cart) and better design and training on equipment can reduce errors. (See "Management of the difficult airway for general anesthesia in adults", section on 'Equipment preparation'.)

Timeouts, briefing, and debriefing — Protocols to verify the correct patient, correct surgery and correct laterality/level should be in place in all ORs.

Before entry into the operating room — In the preoperative area, a two-person check is performed to confirm the patient’s identity using dual identifiers (name, birth date), and ensure that the consent accurately reflects the scheduled surgery and conforms to the patient’s understanding of what will be done (see "Informed procedural consent"). Verification of the exact procedure, side, site, and/or level is the first strategy to avoid wrong procedure and wrong site errors. (See 'Wrong procedure or wrong site errors' below.)

If a regional block is planned, a separate timeout is necessary just before beginning the process of placing the block in the preoperative area (or, in some cases, after entry into the OR) [37,38]. Notably, wrong-side blocks occur as frequently as wrong-side surgical procedures [39-41].

Timeouts and briefing in the operating room — Critical information about the patient and the procedure must also be reviewed and reverified prior to beginning the procedure.

●Timeouts – The brief timeouts performed before induction and before incision must involve participation of the entire OR team (ie, surgeon, anesthesia provider, circulating nurse, scrub technician) and use a standardized checklist such as the Joint Commission on surgical timeouts or the World Health Organization (WHO) surgical safety checklist (table 4 and table 5) [42,43]. Many institutions have modified the WHO checklist to suit their local process, or use another standardized checklist such as that promoted by Association of Operating Room Nurses (AORN) [44]. These timeouts are opportunities to avoid errors by reverifying the patient's identity with dual identifiers, as well as reconfirming the surgical procedure, site, side, and level. (See 'Wrong procedure or wrong site errors' below.)

In a 2018 international meta-analysis that included 11 observational studies with more than 450,000 patients, use of the WHO checklist was associated with reduced postoperative mortality (odds ratio 0.75, 95% CI 0.62-0.92) and complication rates (odds ratio 0.73, 95% CI 0.61-0.88), compared with no use of a checklist [45]. Partial use or poor implementation of checklist use has yielded only limited or short-term improvements [45-47]. A computerized display of the checklist can improve adherence [47].

●Briefing – In addition to or in conjunction with a timeout, a more thorough preoperative surgeon-led briefing should be performed, with all members of the OR team. A paper or electronic checklist is used to verify all critical information, including:

•Introducing each team member and their role.

•Rechecking patient identity (using dual identifiers) and consent, the surgical procedure to be performed, and the site, side, or level of surgery (table 4).

•Brief discussion of goals and critical steps for the procedure, as well as contingency plans.

•Identifying specific issues with the patient’s medical status (table 6).

•Discussing antibiotic administration (if appropriate), including antibiotic selection and dosing (table 7). (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'Antibiotic administration'.)

•Evaluating fire risk and discussing mitigation strategies (eg, reduction of fraction of inspired oxygen [FiO₂]). (See "Fire safety in the operating room".)

•Verifying blood product availability (if appropriate). (See "Perioperative blood management: Strategies to minimize transfusions".)

•Planning postoperative disposition (eg, post-anesthesia care unit [PACU] or intensive care unit [ICU]).

•Inviting all team members to ask questions and to speak up regarding any concerns before or during the procedure [48].

Briefings allow development of a shared mental model, planning for risks and management, and improvement in teamwork and safety [49-54]. Multiple studies have shown that briefings result in better patient outcomes [55], as well as improved teamwork and compliance with best practices [52,54,56].

For emergency surgical procedures, practical alternatives to a standard briefing include a pause for a rapid briefing after the patient is stabilized, or encouraging the surgeon(s) to speak aloud clearly about ongoing and next steps even while they are operating.

Debriefing — At the end of the procedure before leaving the OR, a sign out occurs to ensure that all intended procedures were performed, as well as to learn from any errors or vulnerabilities found [51,53,54,57,58]. Information obtained during debriefings is useful to implement improvements that reduce risk [59]. (See 'Incident and outcome reporting with implementation of system changes' below.)

Specific debriefing tasks in the sign out phase of the WHO surgical safety checklist include (table 5):

●Completion and sign off of sponge and equipment counts (see "Retained surgical sponge (gossypiboma) and other retained surgical items: Prevention and management", section on 'Standardized count protocols')

●Completion of specimen forms for pathology

●Postoperative disposition (including patient instructions for same day surgeries)

●Discussion of any equipment issues, errors or “near misses” that should be reported in the local incident reporting system, and discussion of possible processes to improve safety or efficiency (see 'Incident and outcome reporting with implementation of system changes' below)

Handoffs — We employ standardized handoff protocols during transfer of patient care (eg, from the OR to the PACU or ICU). (See "Handoffs of surgical patients".)

Nontechnical skills — Nontechnical skills to reduce risk include minimizing distractions and maintaining situational awareness and vigilance.

●Minimize distractions – Distractions and disruptions occur frequently during surgery (typically 11 to 12 events per hour) [60,61]. These include equipment alarms, background conversations and music, door openings, and untangling snarled intravenous lines and monitoring cables and wires leading to the patient [62-66].

Distractions can cause flow disruptions and technical errors that have been associated with adverse events and mortality [67-70]. Accumulation of minor events can decrease a surgical team's ability to compensate if a major event occurs [71].

Specific techniques to minimize distractions include:

•Limiting the number of individuals in the OR [64,65,72].

•Reducing noise level from all sources.

•Limiting surgeon interruptions to only those critical to the case.

•Minimizing use of personal electronic devices – A survey of anesthesia providers showed that 24 percent reported texting, 5 percent reported talking on the phone, and 11 percent reported browsing the internet while in the OR, although most recognized that these distractions may impact patient safety [73].

●Situational awareness – Lack of situational awareness is a failure to perceive relevant clinical information or to comprehend the meaning of available information. Lack of situational awareness contributed to death or brain damage in 74 percent of anesthesia closed claims between 2002 and 2013 [74]. Situational awareness is improved by technologies to enhance recognition of changing patient condition (eg, monitor displays [75], pulse oximeter tones [76], multifunction alert displays [77]).

Importantly, individual OR team members should be cognizant of the mental workload of each of the other members since this workload varies across time according the clinician’s discipline [78].

●Manage fatigue – Fatigue and sleep disruption are commonly experienced by providers offering service around-the-clock. Sustained wakefulness for 24 hours results in reduced hand-eye coordination equivalent to a blood alcohol level of 0.1 percent [79]. Any sort of sleep deprivation has implications for clinicians, whether continuous or due to shift work with circadian disruption [80,81].

Scientific data are conflicting around the impact of sleep deprivation, with multiple studies showing that while it decreases performance, patient outcomes are not affected [82-84]. However, in a 2019 meta-analysis comparing nearly 120,000 surgical procedures performed during daytime hours with more than 46,000 procedures performed during after-hours shifts, lower mortality (odds ratio 0.67, 95% CI 0.51-0.89) and lower morbidity (odds ratio 0.71, 95% CI 0.53-0.94) were noted for daytime cases [85]. Likely contributing factors were fatigue in all OR personnel, state of urgency, and availability of resources after-hours.

Strategies proposed to reduce the effect of sleep deprivation include [80]:

•Caffeine intake (200 mg of caffeine can boost performance and alertness).

•Good sleep habits when not doing shift work. This includes regular bedtime and wake times, 8 hours of sleep per 24 hours, and limiting stimulation in the hour prior to bedtime. Planned short naps may also improve alertness and performance [80].

•Scheduling policies to minimize the effects of fatigue. Although sleep deprivation and disruption are unavoidable, seeking out additional work shifts for financial gain should be discouraged.

•Limiting surgical procedures performed after hours to emergencies or urgent procedures.

MANAGEMENT OF SPECIFIC HAZARDS

Wrong procedure or wrong site errors

●Incidence – In the United States, wrong-site surgery continues to represent a large proportion of sentinel events in the Joint Commission database [86]. The problem has not significantly decreased despite various efforts to implement safeguards (table 4 and table 5). Most efforts have focused on the perioperative period. However, errors can occur "upstream" including errors in site marking based on imaging (eg, radiographs, magnetic resonance images [MRIs]).

Notably, many such events involve performance of a wrong site nerve block [39-41] with 0.53 to 5.07 per 10,000 regional blocks [87-89].

●Risk factors – Contributing factors include poor communication, failure to use site markings, incorrect patient positioning, multiple procedures on the same patient, emergency operations, surgeon fatigue, presence of multiple surgeons, unusual time pressures, and/or unusual patient anatomy [11].

●Approaches to risk reduction

•Surgical procedures – Verification of the correct surgical site should occur at multiple times in the perioperative period, as noted above (table 5) [11]. (See 'Before entry into the operating room' above and 'Timeouts and briefing in the operating room' above.)

•Peripheral nerve blocks – A separate timeout should be performed before performing a regional block (stop before you block) [87]. In one study, implementation of preprocedural checklist before performing regional blocks eliminated wrong-side nerve blocks [90].

Medication errors — Strategies to prevent medication errors in the perioperative setting (eg, administration of the wrong medication, wrong dose, or into the wrong site) are reviewed in separate topics. (See "Prevention of perioperative medication errors" and "Intravenous infusion devices for perioperative use", section on 'Risks for medication errors'.)

Potential physical injuries

●Patient positioning injuries – (See "Patient positioning for surgery and anesthesia in adults".)

●Eye injury – (See "Postoperative visual loss after anesthesia for nonocular surgery".)

●Radiation injury – (See "Anesthesia for magnetic resonance imaging and computed tomography procedures", section on 'Radiation risks' and "Radiation-related risks of imaging".)

●Injury due to fire or electrical shock

•Operating room (OR) fire – (See "Fire safety in the operating room".)

•Electrical injury – Although rare, electrical shock in the OR can cause injuries that include burns, cellular death, ventricular fibrillation, respiratory paralysis, or seizures [91]. Patients and staff are at risk of electrical shock or electrocution if they come into contact with a defective device (or a "hot," wire); electricity can flow through their body into the ground (eg, the OR table or the floor).

-General precautions to prevent electrical injury in the OR – Regulations for OR environments are governed by National Fire Protection Association (NFPA-99) code [92]. These settings are defined as a wet procedure location and must be "provided with special protection against electrical shock" using one of the following methods (see "Electrical injuries and lightning strikes: Evaluation and management"):

An isolated power system (IPS) will limit the flow of current to a low value in the event of a first fault. Although the power supply will not be interrupted, the line isolation monitor (LIM) will sound an alarm.

A ground fault circuit interrupter (GFCI) will interrupt the power supply to a device if a ground fault current is detected (typically >5 mA). In this case, the power will be interrupted to that device, which might be dangerous if it is a piece of life support equipment (ie, a heart-lung machine). Notably, the code does not allow for one GFCI device to protect more than one receptacle (ie, so-called daisy chaining).

•Special precautions during use of electrocautery – Electrocautery devices may cause thermal burns, hemorrhage, fire, or other device malfunction. Strategies to prevent these complications are discussed separately. (See "Overview of electrosurgery", section on 'Improving safety' and "Fire safety in the operating room", section on 'Manage ignition sources'.)

Additional precautions are necessary if electrocautery is to be used in a patient with a pacemaker or implantable cardioverter-defibrillator (ICD) device (see "Perioperative management of patients with a pacemaker or implantable cardioverter-defibrillator", section on 'Electromagnetic interference'). Similarly, special precautions are necessary (typically turning off the device before surgery commences) in patients with neuromodulation devices such as deep brain stimulators, vagal nerve stimulators, or spinal cord stimulators if electrocautery is to be used to avoid reprogramming the devices or causing the tip of the electrode to heat up [93].

●Injury due to retained surgical item – (See "Retained surgical sponge (gossypiboma) and other retained surgical items: Prevention and management".)

Accidental awareness during anesthesia — Awareness during general anesthesia can result in pain and psychological distress. Prevention and management are discussed in a separate topic. (See "Accidental awareness during general anesthesia".)

INSTITUTIONAL AND SYSTEMS APPROACHES TO SAFETY IMPROVEMENT

Incident and outcome reporting with implementation of system changes

●Comprehensive patient safety programs – Establishing a comprehensive patient safety program may be the most important approach to reducing risks in the operating room (OR) [94]. This involves reviewing incident reporting systems to identify new or unrecognized system vulnerabilities associated with preventable harm, then redesigning these processes to improve safety, and implementing ongoing audits and monitoring. Successful implementation of system changes requires establishing a culture of safety (rather than a blame and shame approach) that is driven by hospital leadership, but with participation of all personnel in the ORs or other hospital area [6,82].

●Incident and outcome reports

•Incident registries – These registries are modeled on the Aviation Safety Reporting System [83], and have been used to identify system vulnerabilities and reduce risks [82]. Examples of databases or registries for such reports include:

-The Closed Claims Database in anesthesiology [84].

-The Anesthesia Incident Reporting System (AIRS), established in 2011 so that any anesthesia provider can file a report of an adverse event or near miss with either anonymity or confidentiality [95].

-The Australia and New Zealand Tripartite Date Committee (ANZTADC) system and the Canadian Anesthesia Incident Reporting System (CAIRS) [96,97].

-Mandatory reporting systems of adverse events detected with anesthesia information management systems (AIMS) in individual institutions [98].

-Mandatory medical device reports submitted to the US Food and Drug Administration (FDA), and stored in the FDA in the Manufacturer and User Facility Device Experience (MAUDE) database.

•Outcome reports – Prospective monitoring of outcomes using control charts with regular feedback to institutions has been associated with decreased major adverse events, mortality, and intensive care unit (ICU) stays [99]. The effect size in this study was proportional to the degree of compliance after implementation of the improvement plans.

●Implementation of evidence-based best practices – Evidence-based best practices to optimize patient care are developed by a systematic review of evidence weighing both risks and benefits. [100]. Implementation typically requires several years [101]. Ideally, guidelines should include measurements that can be recorded by each institution to track improvements in adherence to standards [102]. (See "Overview of clinical practice guidelines", section on 'Effects of guidelines on practice' and "Overview of clinical practice guidelines", section on 'Implementing practice guidelines'.)

Examples of guidelines used in OR settings include those for antibiotic administration, glycemic control, and maintenance of normothermia [103]. Other guidelines address overlapping surgery (defined as more than one procedure performed by the same primary staff surgeon scheduled such that the start time of one procedure overlaps with the end time of another) [104]. Data for staffing overlapping cases are scant for anesthesia providers. One study that included 578,815 adult patients noted that a ratio greater than 1:2 for staff anesthesiologists supervising other anesthesia providers (eg, residents, Certified Registered Nurse Anesthetists [CRNAs]) was associated with slightly higher combined adverse events (odds ratio 1.15, 95% CI 1.09-1.21) [105].

Team and simulation training

●Formal team training – Team training programs for OR personnel (eg, surgeons, anesthesia providers, nurses, scrub technicians) teach effective communication strategies, how to conduct effective timeouts and briefings, how to challenge other team members when a safety issue is identified, conflict management, and implementation of safe care transitions [106-118]. Similar team training efforts have been successfully implemented in obstetrical units. (See "Reducing adverse obstetric outcomes through safety sciences", section on 'Teamwork training'.)

Team training based on aviation-style nontechnical skills was associated with reduced surgical mortality in a study in Veterans Health Administration (VHA) hospitals [55]. Other aviation-style teamwork training programs have also demonstrated improved performance in the OR; however, positive effects varied among teams and were influenced by the attitude and collaboration of key individuals [114,115]. Another type of teamwork training program is not based on an aviation style (Team Strategies and Tools to Enhance Performance and Patient Safety [TeamSTEPPS]. This training was also associated with reduced overall surgical morbidity and mortality; however, continued team training was required to sustain these improvements over time [110].

●Simulation training – Simulation training is designed to improve management of crisis situations, with uses that include:

•Teaching nontechnical skills (eg, teamwork and communication) [107-109,119]. (See 'Nontechnical skills' above.)

•Testing interventions to reduce error [120].

•Developing and practicing crisis protocols [111,121-127], with standardized simulation-based assessments that identify performance gaps and opportunities for improvement [128]. (See "Reducing adverse obstetric outcomes through safety sciences", section on 'Simulation and drills'.)

•Improving understanding of the effects of stress and fatigue [129-132]. (See 'Nontechnical skills' above.)

•Developing technical skills such as airway management, ultrasound-guided regional block, and central line placement [119].

Formal simulation training often uses high-fidelity programed manikins and elaborate scenarios [111,133]. However, effective interdisciplinary simulation training without expensive models or tools can be accomplished when teams simply walk and talk through a simulated crisis by identifying roles, specifying steps to be taken, and building teamwork [134,135].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Patient safety in the operating room".)

SUMMARY AND RECOMMENDATIONS

●Types of human errors – Individual human errors in the operating room (OR) include communication failures, cognitive errors that are action-based (application of rules or skills) or decision-based (judgment or knowledge), and technical errors. (See 'Types of human errors' above.)

●Approaches to risk reduction

•Standardized checkouts of machines and equipment – (See 'Standardized machine and equipment checkouts' above.)

-Anesthesia machine – Adherence to a standardized pre-use anesthesia machine checkout would avoid most critical incidents related to misuse or failure of the anesthesia workstation (table 3). Preparation should include checking the function of advanced airway and anesthesia and monitoring equipment. (See "Anesthesia machines: Prevention, diagnosis, and management of malfunctions", section on 'Standardized anesthesia machine checkout'.)

•Timeouts, briefings, and debriefing

-Before OR entry – Review of the surgical consent and the initial verification process occur in the preoperative holding area before entry into the OR. This process employs at least two people and ideally includes an anesthesia provider, the surgeon, and a preoperative nurse who all verify patient identity using dual identifiers, as well as the exact procedure, side, site, and/or level. If a regional block is planned, a separate timeout is necessary just before beginning the process of placing the block in the preoperative area (or, in some cases, after entry into the OR). (See 'Before entry into the operating room' above.)

-OR briefing and timeouts – Brief timeouts are performed before induction and before incision, involving participation of the entire OR team (eg, surgeon, anesthesiologist, circulating nurse, scrub technician), and using a standardized checklist such as the Joint Commission on surgical timeouts or the World Health Organization (WHO) surgical safety checklist is typically used (table 4 and table 5). Ideally, in addition to or in conjunction with a timeout, a more thorough preoperative surgeon-led briefing or "huddle" is performed. (See 'Timeouts and briefing in the operating room' above.)

-Debriefing – At the end of the procedure before leaving the OR, a sign out occurs, ideally as part of a more detailed debriefing process. This ensures completion of all steps and identifies hazards and suggested improvements. (See 'Debriefing' above.)

•Handoffs – We employ formal standardized handoff protocols during transfer of patient care from the OR to the post-anesthesia care unit (PACU) or intensive care unit (ICU). (See "Handoffs of surgical patients".)

•Nontechnical skills – Nontechnical skills to reduce risk include minimizing distractions and maintaining situational awareness and vigilance. (See 'Nontechnical skills' above.)

●Strategies to manage specific hazards and system

•Wrong procedure or wrong site – Contributing factors include poor communication, failure to use site markings, incorrect patient positioning, multiple procedures on the same patient, emergency operations, surgeon fatigue, presence of multiple surgeons, unusual time pressures, and/or unusual patient anatomy. Multiple sequential verification opportunities are designed to detect and prevent potential errors. (See 'Wrong procedure or wrong site errors' above and 'Timeouts, briefing, and debriefing' above.)

•Medication errors – (See "Prevention of perioperative medication errors" and "Intravenous infusion devices for perioperative use", section on 'Risks for medication errors'.)

•Potential physical injuries – Potential physical injuries include positioning injuries, eye injury, retention of surgical instruments, and injuries due to radiation, fire, or electrical shocks. (See 'Potential physical injuries' above.)

•Accidental awareness during anesthesia – Pain and psychological distress may result from accidental awareness. (See "Accidental awareness during general anesthesia".)

●Institutional and system approaches to improve safety

•Incident and outcome reporting with implementation of system changes – Incident and outcome reporting is used to identify system vulnerabilities, implement evidence-based best practices, and establish comprehensive safety improvement processes. (See 'Incident and outcome reporting with implementation of system changes' above.)

•Team and simulation training – Team training teaches effective communication strategies during timeouts and briefings, conflict management, and safe care transitions. Simulation training is designed to improve management of crisis situations. (See 'Team and simulation training' above.)