Indiana University-Purdue University Indianapolis (IUPUI) / Intraoperative adverse events (IAEs) due to interprofessional miscommunication continue to occur despite implementation of surgical checklists and focused communication trainings. Much of the previous intraoperative communication research has focused on the content and quantity of interprofessional communication instead of its context and quality, and current communication interventions seem to have varying levels of engagement, effectiveness, and persistence. The purpose of this dissertation study was to explore the psychosocial processes involved during the establishment and maintenance of interprofessional communication surrounding IAEs or potential IAEs in the intraoperative environment and to identify the perceived facilitators and barriers to communication. Twenty surgical team members participated in semi-structured interviews and described their experiences with interprofessional communication during IAEs. Grounded theory methodology was used to identify the central process, Testing the Water, and two subprocesses, Reading the Room and Navigating Hierarchy. Testing the Water describes the situational nature of interprofessional communication as surgical team members navigate factors influencing the context and probable trajectories of surgical cases and the perceptions of professional rights and responsibilities within surgical teams. Participants in this study experienced Testing the Water differently based on their professional roles and tenure; findings were organized around three emerging groups identified as inexperienced nurses, experienced nurses, and surgeons. Interprofessional communication surrounding IAEs occurred for study participants in fluid, iterative phases identified as 1) Recognition, 2) Reconnaissance, 3) Rallying, 4) Reaction, and 5) Resolution. Participants recognized IAEs or potential IAEs, gathered information through reconnaissance, rallied other team members, reacted to stabilize patients, and resolved IAEs through individual or surgical team reflection. Study participants reported using strategies during communication to accomplish two psychosocial goals, preserving the flow of surgical cases, and protecting the ‘face’ of themselves and other surgical team members. Supporting these psychosocial goals through increased psychological safety for all surgical team members potentially leads to more effective, timely surgical team communication. More effective interprofessional communication facilitates the improved situational awareness, collective sensemaking, and integrated team mental models that are critical to coordinated responses to IAEs. The findings of this study suggest practical implications to increase the effectiveness of interprofessional communication in the intraoperative environment.

The understanding of the mesorectal spread in rectal cancer has lead to wide acceptance of total mesorectal excision (TME) as the surgical technique of choice for carcinoma in the lower and mid rectum. While oncological results and survival have improved with TME-surgery, morbidity and mortality remain important issues. The most feared complication is symptomatic anastomotic leakage. The aim of this thesis was to focus on the role of the defunctioning stoma, risk factors, and postoperative monitoring in regard to anastomotic leakage in sphincter saving resection of the rectum. Intraoperative adverse events were analysed in a retrospective population based case-control study in which all patients who underwent elective anterior resection in Sweden between 1987 and 1995, and who died within 30 days or during the initial hospital stay (n=140), were compared with patients chosen at random (n=423) who underwent the same operation during the same period, but survived the operation. Intraoperative adverse events were more frequent in those who died, and reconstruction of an anastomosis judged unsatisfactory by the surgeon improved the outcome. In a population based retrospective case-control study, risk factors for symptomatic anastomotic leakage were investigated in randomly chosen sample of patients who underwent anterior resection in Sweden between 1987 and 1995 (n=432). Twelve per cent of the patients developed symptomatic leakage, and 25% of the patients with leakage ended up with a permanent stoma. In multivariate regression analysis, low anastomosis, preoperative radiotherapy, male gender and intraoperative adverse events were independent riskfactors for anastomotic leakage. In a randomised multicentre trial patients operated with sphincter saving TME¨surgery for rectal cancer were randomised to a defunctioning stoma (n=116) or not (n=118). The overall rate symptomatic leakage was 19%. Patienst without a defunctioning stoma leaked in 28% and patients with a defunctioing stoma in 10%, a statistically significant difference (p<0.001) not previously demonstrated in any randomised trial of adequate size. Postoperative monitoring with computed tomography scan (CT-scan) on postoperative day 2 and 7, and C-reactive protein (CRP) daily in 33 patients operated on with anterior resection of the rectum, demonstrated larger pelvic fluid collections in patients with leakage before the leakage was clinically diagnosed. CRP was increased from postoperative day 2 and onwards in patients in whom clinical leakage was diagnosed on median postoperative day 8. In 23 patients who underwent anterior resection of the rectum, intraperitoneal metabolism was investigated using microdialysis technique measuring the carbohydrate metabolites lactate, pyruvate and glucose. Intraperitoneal cytokines IL-6, IL-10 and TNF-α were collected through a pelvic drain and analysed. In patients who developed leakage, the latate/pyruvate ratio was increased near the anastomosis on postoperative day 5 and 6, as well as IL-6 and IL-10 which were increased postoperatively day 1 and 2, while TNF-α was higher on day 1.

Bakgrund: En stor del av vårdskadorna i Sverige beror på undvikbara händelser i samband med kirurgiska ingrepp och årligen anmäls hundratals lex Maria anmälningar till Inspektionen för vård och omsorg för utredning. Riskerna i den intraoperativ vården är väl kända, men kunskapen om avvikelserna som faktiskt inträffat är liten. Syfte: Studiens syfte var att beskriva inrapporterade allvarliga avvikelser som uppstått under intraoperativ vård och lett till lex Maria anmälningar. Metod: En kvantitativ innehållsanalys av 173 lex Maria anmälningar som skett under intraoperativ vård. Pearson’s korrelationsanalys utfördes för att studera statistiska samband mellan variabler. Resultat: Vid analys av lex Maria anmälningarna framkom 11 kategorier som beskriver vilken typ av händelse som lett till allvarlig vårdskada eller risk för allvarlig vårdskada. De 11 kategorierna är; Operation utförd på fel sätt 17,71 %, oavsiktlig vävnadsskada 15,43 %, fel läkemedelshantering 12,57 %, kvarglömt material 11,43 %, felhantering av medicintekniska produkter 9,14 %, operation av fel område 6,86 %, felpositionering 6,29 %, förväxlad anatomi 5,71 %, brist i patientövervakning 5,14 %, kommunikationsbrister 5,14 % och fel på medicinteknisk produkt 4,57 %. Det framkom att stor del av patienterna behövt genomgå ytterligare ingrepp, fått en skadad kroppsfunktion och fått ett ökat vårdbehov, till följd av händelsen. Slutsats: Det förekommer flera risker som hotar patientsäkerheten under den intraoperativa vården och dessvärre var det en stor del av anmälningarna där patienter drabbats av allvarliga vårdskador. Resultatet kan bidra till medvetenhet om de omständighet som leder till en kirurgisk vårdskada. / Background: A large part of the healthcare injuries in Sweden are due to adverse events in surgical settings, and hundreds of adverse events (lex Maria) are reported annually to the Swedish healthcare authority for investigation. The risks in intraoperative care are well known, but knowledge of the adverse events that actually occurred is small. Aim: The aim of the study was to describe reported serious adverse events that occurred during intraoperative care and led to lex Maria reports. Method: A quantitative content analysis of 173 lex Maria reports that took place during intraoperative care. Pearson’s correlation analysis was performed to study statistic correlation between variables. Results: In the analysis of the lex Maria reports, 11 categories emerged that describe the type of event that led to serious care injury or risk of serious care injury. The 11 categories are; Surgery performed incorrectly 17,71 %, unintentional tissue damage 15,43 %, incorrect drug management 12,57 %, retained foreign objects 11,43 %, incorrect management of medical devices 9,14 %, wrong site surgery 6,86 %, incorrect positioning 6,29 %, mixed up anatomy 5,71 %, lack of patient monitoring 5,14 %, communication deficiencies 5,14 % and errors in medical device 4,57 %. It was also found that a large proportion of patients needed further surgical intervention, received an impaired bodily function and had an increased need of care as a result of the events. Conclusion: There are several risks that threaten patient safety during intraoperative care and unfortunately a large proportion of patients suffered health care injuries. The result can contribute to awareness of the circumstances that lead to a surgical care injury.