Safety hazards in abdominal surgery related to communication between surgical and anesthesia unit personnel found in a Swedish nationwide survey

Katarina Göransson, Johan Lundberg, Olle Ljungqvist, Elisabet Ohlsson, Gabriel Sandblom

Many adverse events occur due to poor communication between surgical and anesthesia unit personnel. The aim of this study was to identify strategies to reduce risks unveiled by a national survey on patient safety. During 2011-2015, specially trained survey teams visited the surgery departments at Swedish hospitals and documented routines concerning safety in abdominal surgery. The reports from the first seventeen visits were reviewed by an independent group in order to extract findings related to routines in communication between anesthesia and surgical unit personnel. In general, routines regarding preoperative risk assessment were safe and well- coordinated. On the other hand, routines regarding medication prior to surgery, reporting between the different units, and systems for reporting and providing feedback on adverse events were poor or missing. Strategies with highest priority include: 1. a uniform national health declaration form; 2. consistent use of admission notes; 3. systems for documenting all important medical information, that is accessible to everyone; 4. a multidisciplinary forum for the evaluation of high-risk patients; 5. weekly and daily scheduling of surgical programs; 6. application of the WHO check list; 7. open dialog during surgery; 8. reporting based on SBAR; 9. oral and written reports from the surgeon to the postoperative unit; and 10. combined mortality and morbidity conferences. One repeatedly occurring hazard endangering patient safety was related to communication between surgical and anesthesia unit personnel. Strategies to reduce this hazard are suggested, but further research is required to test their effectiveness.