Anne van Dalen

130 I Chapter 4 Team debriefing comment notes Suboptimal communication During the debriefings the team realized that it is important to timely and regularly provide updates on the progress of the procedure or patient’s status. It became clear that often surgeons felt there was no reason to communicate progress as it was assumed by them this would lead to irrelevant communication. Or it was assumed that an event, such as a minor bleeding or a longer period of hypotension, was irrelevant to know for others as it was believed not to acquire their specific or immediate attention. During debate, it was realized that these assumptions often proved to be false. Surgeons also often assumed that other team members, and the anesthesiologists in particular, could clearly hear the surgeon asking questions or giving directions. During the debriefings surgeons came to realize this was usually not the case. Directions got lost in the chatter and noises generated by equipment in the OR. Team members realized that the closed- loop communication technique -which was often not followed- , deserves to be respected in order to avoid miscommunication. Safety and reliability issues Risks to the sterile field were discussed, such as the surgeon holding the instrument under the armpit during a quick instrument change, instead of handing it over to the scrub nurse. As a result of the debriefing, this particular surgeon became aware of this, and changed her operative set-up. They decided that in the future, the scrub nurse should actually stand on the right, instead of the left side. This was believed to result in a more efficient workflow and better teamwork, subsequently reducing chances of severing sterility. During the debriefings, it was repeatedly noticed that the team did not report a monitor malfunction to the technical staff. This resulted in a recurring sterile field breach every time the monitor ‘ran away’ thereby accidently touching the sterile drape. No one felt responsible enough to report the malfunction, because there was no protocol indicating who is actually responsible for reporting faulty equipment.