Visiting Professor, Anesthesia and Emergency Medicine, Center for Patient Safety, Utrecht University Medical Center, The Netherlands.
Principal and Director, Research, Anshen+Allen Architects, USA.
Health care is plagued by an insurmountable abundance of medical errors. It is estimated that over 100,000 preventable deaths occur each year in the U.S. hospitals alone. This is equal in magnitude to a 747 jumbo jet liner crashing every three days with no survivors aboard. While there are only limited data identifying the role that the built environment contributes to medical errors, this knowledge is on the increase as part of a growing area of interest known as evidence-based design (EBD). It is clear that facility design has an impact on safety – either beneficial or detrimental – depending on how each particular facility is designed.
At the same time the world is in the midst of the largest hospital construction boom in half a century. There remains a large disconnect between designers and facility users with the result that little formal knowledge is implemented in preventing patient harm by better building design. This disconnect is particularly apparent in designing peri-operative settings (i.e., pre-op, surgical operating room, interventional procedure suite, recovery room).
Additionally, medical advances are causing some traditional departmental boundaries to disappear, yielding new types of procedural spaces in which modern medicine is practiced. This in turn is changing medical culture as specialists collaborate in ways that differ from past tradition. Nowhere is this change more apparent than in the convergence of surgery and interventional radiology1.
The epidemic of preventable medical errors, the growing need for healthcare facilities designed for safety, and the convergence of surgery and imaging are resulting in new types of space where medical technology is complex and where safe environments are essential2.
Researchers have found that approximately 10.5% of all adverse medical events and 19.7% of all serious adverse medical events may be related to surgery while many others are related to medical imaging. Categories of medical errors and safety include wrong site surgery, wrong person surgery, radiation exposure, magnetic resonance imaging accidents and hospital-acquired infections. While the majority of these errors may not be directly related to facility design, knowledge of how the built environment affects safety and medical and outcomes is essential in designing healthcare facilities that do not further contribute to unnecessary iatrogenic outcomes (a condition that has resulted from treatment, as either an unforeseen or inevitable side effect).
One theory among practitioners of evidence-based design is that if all operating rooms and other procedure rooms are configured identically (sometimes referred to as handed or universal rooms) the rooms would be safer because during an emergency staff would intuitively know where to look for supplies and instruments because they would all be in the same place regardless of which room they were in. While this hypothesis seems logical there’s no quantifiable evidence supporting this conclusion. Furthermore, if all rooms look alike, they might actually contribute to an increase of wrong person surgery due to the lack of visual cues, such as distinctive landmarks in the room providing guidance to which room, and thus which patient, the staff is attending to. Therefore, if operating rooms are “handed” some form of distinguishing accent or landmark should be provided.
Radiation emitting devices continue to become safer. However, permissible accumulated levels of radiation exposure are rapidly becoming more conservative. As a result, radiation shielding requirements continue to become more stringent, even as most radiology equipment is becoming more reliable. In addition, there is growing interest in associating the long-term effects of radiation exposure with an increased incidence of survivor cancer. While most imaging facilities are designed to ensure adequate radiation protection, surgical facilities are not always designed with this in mind. As surgery becomes increasingly dependent on image guidance, adequate radiation protection becomes more critical. For example, many operating rooms where x-ray technology is used typically rely on small ceiling-mounted lead shields and surgical staff wearing personal radiation protection. However, dedicated space is rarely provided for technologies that control the imaging equipment to work within a radiation controlled zone. Some surgical suites are being outfitted with control rooms (similar to those found in diagnostic imaging departments) adjacent to the operating room anticipating the increased frequency and complexity of radiation emitting devices being used within the operating room.
Accidents related to ferrous objects inappropriately brought into an MRI suite are one of the top ten safety concerns of healthcare executives. While very few deaths caused by ferrous objects pulled into a magnet have been documented, accidents of this nature are known to occur frequently. As a result of one fatality in 2001 the American College of Radiology (ACR) developed a white paper with guidelines for designing safe MRI suites. While these guidelines are relatively easy to apply to MRI suites used for diagnostic imaging it is challenging to incorporate them into the design of intra-operative MRI (I-MRI) suites. This is because intra-operative MRI procedures often require surgical instruments that are attracted by magnetic field to be used in close proximity to the magnet itself. Therefore, the design of intra-operative MRI suites requires particular attention be placed on safeguards such as metal detectors, that alert staff when metal objects are brought into the general vicinity of the magnet.
Minimally invasive surgery (MIS) is typically performed in operating rooms with very low levels of illumination, in order to better visualise anatomical information. Because-as the name suggests- minimally invasive surgery is not an “open” surgical procedure the flat panel monitors are the essential “eyes” of the surgical team and provide a multitude of indispensable data to guide the procedure.
Performing complicated procedures in a dark room in and of itself is dangerous leading to staff tripping accidents, miscommunication and degradation in performance. Cables, tubes and wires connecting various medical and information management systems create additional tripping hazards. Therefore, it is advisable to mount devices on walls and ceilings wherever practical when this can eliminate cables that cross paths of traffic. Wireless devices may also reduce the need for cables and wires. In addition, there is growing interest in illuminating operating rooms with green colored lights, as research by the US Navy has demonstrated improved visualisation of data on flat panel monitors while still maintaining a relatively high illumination level throughout the room. Green surgical lights are another seemingly good idea, with insufficient data, to prove or disprove its efficacy.
Surgical suites and imaging suites are both areas where medical errors can occur commonly and where the built environment has a profound impact on injuries to patients and staff, medical outcomes and overall safety and well-being. When the practices of surgery and imaging are integrated into one comprehensive area-as is becoming increasingly more common-designing these spaces for safety and improved medical outcomes becomes increasingly more complex and costly.
Design is more complicated because each medical specialty has different traditions of work flow, different regulatory guidelines that govern how they perform medical procedures and they often use different instruments and supplies (i.e., disposable versus reprocessed instruments). Therefore, designers of integrated surgical and imaging facilities need to prioritise the importance of safety as an essential concern in their designs. Understanding the impact that designs have on patient well-being is essential.
Key safety issues to consider include reducing nosocomial infection rates, helping prevent wrong site and wrong person procedures, protecting people from unnecessary radiation exposure and helping prevent MRI accidents. Several organizations provide information about reducing medical errors, improving healthcare safety and learning more about evidence based design. These include: the Institute for Healthcare Improvement (IHI) www.ihi.org, The American College of Radiology (ACR) www.acr.org, The American College of Surgeons (ACS) www.facs.org, The American Society of Anesthesiologists (ASA) www.asahq.org. and The Center for Health Design www.healthdesign.org.
1. Rostenberg, B.; The Architecture of Medical Imaging; pp. 360-383; John Wiley and Sons, 2006
2. In August of this year, the Quality Colloquium on the campus of Harvard University assembled several hundred international healthcare leaders to discuss solutions for patient safety, health care quality improvement and medical errors reduction for healthcare executives, clinicians and patient care staff. This article’s authors were part of the colloquium. Doctor Paul Barach was a key organizer of the event and colloquium co-chair, and presented several topics on medical errors and safety. Bill Rostenberg was invited to speak about the role of facility design in improving safety and reducing medical errors. Both authors also presented their findings at this year’s Healthcare Design’07 meeting, a national healthcare design conference presented jointly by The Center for Health Design and the American Institute of Architects/Academy of Architecture for Health. This article is based on those presentations and summarizes both the challenges and potential solutions of building safer surgical/imaging facilities.