Methods
We surveyed surgical team members' perceptions and attitudes using a cross-sectional design that included 427 surgical team members (surgeons, operating room nurses, anaesthetists, and nurse anaesthetists). Participants were identified from employment lists provided by staff managers. All participants worked in the central operating unit (COU).
Organisational Context
The study was conducted at a tertiary university hospital in western Norway (Haukeland University Hospital). The COU has 22 operating rooms, conducting 15,000 operations annually. The operations comprised orthopaedic; cardiothoracic; neuro; ear, nose, and throat (ENT); plastic; urologic; gastroenterological; and endocrine surgeries. The operating room personnel except for surgeons are administered by the Department of Anaesthesia and Intensive Care. Time Out protocols, safety climate instruments, and root cause analysis were not conducted either before or when this study was carried out in February 2009. One section of the care unit was familiar with a pre-anaesthetic induction checklist. An electronic adverse event reporting system was used throughout the hospital. In a concurrent mapping of organisational (neurosurgery and orthopaedic) standards, we found that patient identity was routinely checked at the ward, and further name tags were scanned when patients entered the COU. However, if there was uncertainty about patient identity or body site markings, patients were not routinely returned to the ward (Personal communication by SM, ASH and ES).
Questionnaire
The questionnaire consisted of 14 items, 11 of which had dichotomous responses (0 = no; 1 = yes) and 3 of which had responses scored on an ordinal scale (items 7–9) (never = 0; sometimes = 1; often = 2; always = 3). Items reflected team members' own experience of near misses or mistakes; their strategies for ensuring the correct patient, side, and procedure; questions about whether they believed that such mistakes could have been avoided by using the Time Out protocol; and how they might accept the introduction of the protocol into the COU. The survey also contained an open-ended question that allowed respondents to offer their opinions on the topic. The 14 items are listed in Table 1. The survey also included questions about participant characteristics such as profession, experience, and gender.
The survey was pilot tested by 10 research fellows and medical staff who reviewed the functionality of the electronic system and the adequacy and relevance of the questions. The expert panel regarded the validity of the questionnaire as appropriate in terms of its design and content. The initial review resulted in minor adjustments of sample characteristics; i.e., changing the self-report of professional experiences into years practising instead of categorising professional experiences into different groups.
Data Collection
The survey was distributed to all eligible medical personnel through our hospital email system. We used a web-based questionnaire with an information letter and a direct link to the questionnaire itself. The questionnaire had to be submitted within four weeks. To increase the interest of potential respondents prior to distribution, we also promoted the survey on the hospital intranet page and on wall posters in the COU. The hospital managers provided access for survey recruitment at staff meetings.
Statistics
Descriptive statistics were used to quantify the respondents' characteristics. Analysis of differences within professions and between professions, as well as the safety items, was performed with the Pearson's chi-squared test. P-values were two-sided, and the significance level was 0.05. All data were analysed using SPSS version 18. Qualitative content analysis was used to evaluate surgical team members' experiences of incorrect surgery and to assess patient safety issues reported in the open-ended question.
Ethics
The study was reviewed and approved by the Committee for Medical Research Ethics of the Western Norwegian Regional Health Authorities and the Norwegian Social Sciences Data Services. Permission to perform the study was also granted and endorsed by the hospital management. Respondents agreed to participate by answering the questionnaire. The Department of Research and Development preserved electronic data anonymity and assisted in administering the survey. Data were secured in the hospital research server; the study complied with the Helsinki Declaration.