Safer Surgery part 48 pps

This page has been left blank intentionally Chapter 27 Behaviour in the Operating Theatre: A Clinical Perspective Nikki Maran and Simon Paterson-Brown As clinicians, we have spent many thousands of hours working in operating theatres over the last 20 years. As a senior anaesthetist and surgeon, we recognize that we have a great deal of inuence on the atmosphere created in the operating theatre and that our behaviour inuences those around us. However, as trainees we experienced many different ‘regimes’ in a variety of theatres in which we were trained. There has always been a steep hierarchy within any surgical team and there was no question but that the senior surgeon was the leader. The only time this might ever have been in doubt was where there was an equally formidable theatre sister or anaesthetist in post. Voices were raised, instruments thrown, brows mopped and tears shed. These were not environments in which one questioned decision- making or challenged leadership if one wished to set foot in the operating theatre again! We tended to work in small clinical teams or ‘rms’ with little turnover of staff so everyone knew each other fairly well and teams became well oiled in ‘routine practice’. Although few protocols as we recognize them today existed, deviation from the team routine was seldom tolerated. Patients died, usually because they had co-existing medical disease and occasionally, due to some technical failure during surgery, at least these were the only things we measured. Occasional emergency situations arose which resulted in a patient’s death and these ‘unfortunate’ events were often regarded as ‘unavoidable’ complications of surgery. Occasionally a culprit was identied and usually publically vilied in departmental mortality meetings. As junior doctors, we provided continuity of care by working over 100 hours per week and specialist training lasted eight to ten years. The major focus of training was in the development of good technical skills and these were honed to a high level through an apprenticeship style of training by ‘practising’ on patients. Examinations measured knowledge and everyone knew the trainees who were ‘good with their hands’. The system had massive training redundancy which gave us all plenty of time to ‘absorb’ the implicit skills which were not part of the curriculum – those of picking up cues in the clinical environment – Situation Awareness (SA), developing good clinical judgement – decision-making and developing our own teamwork and leadership skills by modelling our behaviours on those demonstrated to us by our seniors. Many of those who did not develop good SA or decision-making would fail to reach the senior registrar grade, however, Safer Surgery 446 leadership behaviours, styles of communication and modes of teamworking were more subjective. The development of non-technical skills (NTS) has therefore been an implicit, though recognized, part of the medical curriculum for generations. Although the focus of scrutiny in health care is often on failures and adverse events, we are well aware that, in clinical practice, many potential adverse events are avoided when individuals within the team pick up and act on early warning signs. This phenomenon is recorded in studies (de Leval et al. 2000, Catchpole et al. 2007) which demonstrate that high performing teams show greater ability to recover from minor errors. Over the last 20 years, the health service has changed enormously. Medicine and surgery have become more complex, we are able to keep frail patients alive for much longer and so our patient population is becoming older and sicker. This is well summed up by a quote from Chantler who said that where ‘Medicine used to be simple, ineffective and relatively safe, now it is complex, effective and potentially dangerous’ (Chantler 1999, p. 1181). We have learned from other high reliability domains and are now aware that human factors are implicated in many of the things which go wrong in hospitals and indeed in the operating theatre. Indeed, the underlying causes of adverse events in healthcare are more likely to be associated with behavioural failures than a lack of technical expertise (Bogner 1994, 2004) Thankfully, ‘bad’ behaviour in the operating theatre has improved. Throwing of instruments and temper tantrums are now a thing of the past. However, a recent survey of surgical trainees in Scotland revealed that in some areas as many as 50 per cent of trainees reported experiencing bullying by senior staff which made them feel unable to express their views (National Trainee Survey 2007), and this is clearly liable to inuence how likely these trainees are to speak up if they observe problems in the operating theatre. This nding is unlikely to be unique to Scotland. Streamlining of training has reduced the number of years for specialist training and introduction of the European Working Time Directive (EWTD) and similar limits to working hours in other countries has progressively reduced the number of hours that doctors are permitted to work. While on one hand, reduction in hours of work has been demonstrated to reduce error in clinical environments (Lockley et al. 2004), the increase in shift working increases the number of handovers of complex patient care and highlights the need for good and effective communication. The reduction in hours of training time means that we no longer have the luxury of training redundancy and need to make all parts of the curriculum explicit. While this has been done well for the knowledge and technical-skill-based competencies, there is now an urgent need to dene the implicit skills (such as non-technical skills) required to work in the healthcare system and to embed them into the curriculum (Glavin and Maran 2003). The xed ‘rm’ team has been replaced by transient teams of individuals who may come together for only short periods and once again this highlights the need for individuals to develop portable team skills, or non-technical skills, which will equip them to work in these situations. This Behaviour in the Operating Theatre 447 book brings together, for the rst time, the leading researchers who are carrying out observational research in the operating theatre. We have been lucky enough to be directly involved in the work of some of these groups and have learned much from the others. It is useful, perhaps to consider how this work can be of relevance to the operating theatre clinician. Some seminal studies (Brennan et al. 1991, Vincent et al. 2001) and government responses to these (Kohn et al. 1999, Department of Health 2000) have helped us to understand the importance of human factors in adverse events and have driven much of the patient safety agenda. All of the researchers who have contributed to this volume have helped to increase our understanding of how non-technical skills inuence the way we work more specically in the operating theatre. Increasing our understanding of where things are going wrong will help us to develop strategies to deal with these issues or to focus training on improving the situation. Although we like to think that behaviour in the operating theatre has improved over the last ten years, it is sobering to look at the ndings in observational work. What is described is exactly what happens – it is just that it is so ‘normal’ that we don’t notice how absurd our behaviour can sometimes be. Many problems in the operating theatre stem from the ineffectiveness or lack of communication (see Lingard et al., Chapter 17 in this volume). Although communication is a major component of undergraduate and postgraduate curricula, the emphasis is almost exclusively on doctor–patient or nurse–patient communication and very little if any consideration given to the importance of doctor–doctor or doctor– nurse communication. This issue is now being addressed in various safety tools which are being introduced including the WHO patient safety brieng tool (World Health Organization) and the use of SBAR (Situation, Background, Assessment, Recommendation) (Leonard et al. 2004) as part of the IHI initiatives in improving handovers. The non-technical skills taxonomies (Fletcher et al. 2003, Yule et al. 2006) which have been developed not only give us a vocabulary with which to express and discuss non-technical skills ourselves but also a framework which can be used to give feedback to help understand where we are and improve our own non-technical skills. The denition of non-technical skills also helps to allow us to integrate these skills into curricula (Canadian Patient Safety Institute 2005, National Patient Safety Education Framework 2004) and we will increasingly see non-technical skills being incorporated into workplace-based assessment. Using these taxonomies in clinical practice (see Glavin and Patey, Chapter 11 in this volume) will help us to recognize when trainees are failing to develop good NTS early and introduce remediation. Further research is needed to explore whether this can be effective and if not, this clearly has implications for selection in the future. Many of the research groups included in this volume are working in simulation environments. The delity of the training mannequins which are now available means that the simulator is the ideal place to study behaviour in emergency situations without having to wait for these unusual events to happen in real practice Safer Surgery 448 (Flin and Maran 2008). The same situation can be recreated on multiple occasions to allow observation of cohorts of participants. Although human factors training can commence in the classroom, in order to develop skills, individuals need feedback on behaviours and an opportunity to practise these skills. The simulator provides an optimal environment which is safe for both patient and learner to allow observation of self and rehearsal of skills. Simulators will clearly have a role to play in helping individuals to develop the skills required in emergency situations and are also likely to have a role in ‘remedial’ training. The delity of the surgical simulators currently available is still not high enough to allow good intra-operative non-technical skills training for surgeons. However this is likely to be overcome in the next few years as the technology develops and simulators become more widely available. Transfer of skills from the simulator to clinical practice is vital and NTS frameworks such as ANTS and NOTSS are designed to give feedback in both the simulated environment and in the operating theatre. The development of our understanding of the impact of non-technical skills on patient outcomes should also be reected in the use of systems to analyse behaviours when errors occur such as during incident reporting and morbidity and mortality meetings. The Australian AIMS study (Webb et al. 1993) analyses critical incidents from a human factors perspective, but this methodology should be more widely used. Challenges for the future include training trainers to become familiar with assessing and providing feedback on non-technical skill as (see Graham et al., Chapter 12 in this volume) have clearly demonstrated that inter-rater reliability of such systems is not high unless assessors are both experienced in the observation of skills and have been well calibrated. The aviation model of trainer accreditation for both teaching and assessing non-technical skills (Civil Aviation Authority 2003) is one that we can only aspire to in healthcare. We have come a long way in healthcare over the last ten years and many of those who have contributed to this book have helped to drive this change. In the next ten years, non-technical skills will become an implicit part of the curriculum for doctors, nurses and all other health professionals involved in the delivery of healthcare. As a result, the assessment of non-technical skills will become the norm, and understanding the importance of non-technical skills in certain specialties will drive the need to identify individuals with good NTS early in training for selection to certain specialities. Future generations will nd the operating theatre a very different place to work in and, as a result, ultimately a safer place for patients. References Bogner M. (ed.) (1994) Human Error in Medicine. Hillsdale, NJ: LEA. Bogner M. (ed.) (2004) Misadventures in Health Care. Mahwah, NJ: LEA. Brennan, T., Leape, L., Laird, N.M., Herbert, L., Localio, A.R., Lawthers, A.G., Newhouse, J.P., Weiler, P.C. and Hiatt, H.H. (1991) Incidence of adverse Behaviour in the Operating Theatre 449 events and negligence in hospitalised patients: Results of the Harvard Medical Practice Study I. New England Journal of Medicine 324, 370–6. Canadian Patient Safety Institute. (2007) Safety Competencies Framework – Groundbreaking Project on Interprofessional Education. Available from: <http://www.patientsafetyinstitute.ca/education/safetycompetencies.html> [last accessed March 2009]. Catchpole, K.R., Giddings, A.E., Wilkinson, M., Hirst, G., Dale T. and de Leval, M.R. (2007) Improving patient safety by identifying latent failures in successful operations. Surgery 142(1), 102–10. Chantler, C. (1999) The role and education of doctors in the delivery of healthcare. Lancet 353, 1178–81. Civil Aviation Authority (2003) Crew Resource Management (CRM) Training. Guidance for Flight Crew, CRM Instructors (CRMIS) and CRM Instructor- examiners (CRMIES). CAP 737. London: Civil Aviation Authority. de Leval, M.R., Carthey, J., Wright D.J. and Reason, J.T. (2000) Human factors and cardiac surgery: A multicenter study. Journal of Thoracic Cardiovascular Surgery, 119, 661–72. Department of Health (2000) An Organisation with a Memory: Learning from Adverse Events in the NHS. London: The Stationery Ofce. Fletcher, G., Flin, R., McGeorge, P., Glavin, R., Maran, N. and Patey, R. (2003) Anaesthetists’ Non-Technical Skills (ANTS): Evaluation of a behavioural marker system. British Journal of Anaesthesia 90(5), 580–8. Flin, R. and Maran, N. (2008) Non-technical skills. In R. Riley (ed.) Simulation in Medicine. Oxford: Oxford University Press. Glavin, R.J. and Maran, N.J. (2003) Integrating human factors into the medical curriculum. Medical Education 37(Suppl.1), 59–64. Kohn, L, Corrigan, J and Donaldson, M. (eds) (1999) To Err is Human. Building a Safer Healthcare System. Washington, DC: Institute of Medicine National Academy Press. Leonard, M., Graham, S. and Bonacum, D. (2004) The human factor: The critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care 13(Suppl 1), i85–i90. Lockley, S., Cronin, J., Evans, E., Cade, B., Lee, C., Landrigan, C., Rothschild, J., Katz, J., Lilly, C., Stone, P., Aeschbach, D., Czeisler, C. and Harvard Work Hours, Health and Safety Group (2004) Effect of reducing interns’ weekly work hours on sleep and attentional failures. The New England Journal of Medicine 351(18), 1829–37. National Patient Safety Education Framework (2004) An Initiative of the Australian Council for Safety and Quality in Health Care. Available from: <http://www. patientsafety.org.au/framework/index.html> [last accessed 11 March 2009]. National Trainee Survey (2007) Postgraduate Medical Education and Training Board. Available from: <www.pmetb.org.uk/reports> [last accessed March 2009]. Safer Surgery 450 Safe Surgery Saves Lives (2008) World Health Organization. Available from: <www.who.int/patientsafety/safesurgery/> [last accessed March 2009]. Vincent, C., Neale, G. and Woloshynowych, M. (2001) Adverse events in British Hospitals: Preliminary retrospective record review. British Medical Journa, 322, 517–19. Webb, R.K. Currie, M., Morgan, C.A., Williamson, J.A., Mackay, P., Russell, W.J. and Runciman, W.B. (1993) The Australian Incident Monitoring Study: An analysis of 2000 incident reports. Anaesthesia and Intensive Care 21(5), 520–8. Yule, S., Flin, R., Paterson-Brown, S., Maran, N. and Rowley, D. (2006) Development of a rating system for surgeons’ non-technical skills. Medical Education 40, 1098–104. Index A-TEAM 129 behaviour categories 132 development of 136–7 feedback 138 in the operating theatre 141–4 rationale 130–36 summative assessment 138, 141 training 137–8 adverse events 12–13, 151, 445, 446–7 all team members’ behaviour scale see A -TEA M alpha-amylase analysis 377–8 American Society of Anesthesiologists (ASA) scores 264 anaesthesia adaptive coordination 204–15, 225–33 observation systems 228–33 task-analytic approach 234 behavioural markers 308–9 clinical guidelines 371–80 coding reliability 230–31 collaborative management of unexpected events 225–8 communication 241–55, 311–15, 316, 399 coordination behaviour 203 data recording 230 emergence 246–9 experts’ judgement 309 handover from 249–55 human factors 305 induction 244–6 nonroutine events (NRE) 205 observation evaluation tools 308–10 observational studies 231–3 participants in study 306 problem solving 303–5 shared mental models 315 simulators 304 study results 311–12 teamwork 203–4 training scenarios 306–8 transitions 244 Anaesthetists’ Non-Technical Skills System (ANTS) development 176–7 information gathering 181–2 intraclass correlation (ICC) 195 lessons learnt 199–200 methodology 190 misclassication 198 promotion of 177–9 qualitative data 196–9 questionnaires 196–7 rater training 193–5 safety standards 198–9 study design 190 taxonomy 209, 214–15 teaching 180–83 trainee assessment 185–6 video 190–93 workplace-based assessment 179–80, 189–200 AN ZCA ( Australian and New Zealand College of Anaesthetists) 189 ASA ( A merican Society of Anesthesiologists) 264 audio-video recording 388–90 Australian and N ew Zealand College of Anaesthetists (ANZCA) 189 behaviour scales and teamwork 130, 132–4 Behavioural Marker Risk Index (BMRI) 266–7, 271–2 behavioural markers 263, 273, 423–35 anaesthesia 308–9 Non-Technical Skills for Surgeons (NOTSS) 14 rating of 194–5 Safer Surgery 452 scores 270–71 systems 85, 263 BMRI (Behavioural Marker Risk Index) 266–7, 271–2 C anME DS 353 Case Based Discussion (CBD) 180 CIT (critical incident technique) 13 clinical competence, assessment of 28 clinical environment, interruptions 406 clinical guidelines 371–2 observations 374–5 simulator-based evaluation 372–4 Cognitive Task Analysis 14 commodity approach to healthcare 442 communication anaesthesia 241–55, 311–15, 316, 399 operating theatre (OT) 118, 286–8 problem solving 301–16 surgery 273–4 surgical performance 283–97 teamwork 143–4, 156–7, 283–97 coordination behaviour 203 cortisol analysis 377 costs of incidents 169 crew resource management (CRM) 67, 153–5, 302, 423–5 in aviation 425–6 healthcare 433–5 in medicine 426–33 critical incident technique (CIT) 13 CR M see Crew Resource Management decision-making see surgical decision- making Directly Observed Procedural Skills (DOPS) 180 Disruptions in Surgery Index (DiSI) 408–9 DOPS (Directly Observed Procedural Skills) 180 double-loop learning 155 emergency department, interruptions 406–7 environmental psychology 406 ergospirometry 375–7 European Working Time Directive 8, 29, 274 failure source model 322, 329–31 followership 134–6 heedful interrelating 207–8 ICC (intraclass correlation) 195 I ndependent Sector T reatment Centres (ISTC) 29 infant simulators 372–4 innovation 438 instrument nurses see scrub nurses IN TERAC T 209 intraclass correlation (ICC) 195 I STC (Independent Sector Treatment Centres) 29 JA (Judgement Analysis) 364–6 J ARTEL (Joint Aviation Requirements: Translation and Elaboration of Legislation) project 14 Judgement Analysis (JA) 364–6 Kaiser Permanente, surgical safety programme 274–8 latent failures 151 leadership 134–6, 154, 445 learning, double-loop 155 Line Operations Safety Audit (LOSA) 85, 424, 433 logistic regression model 267 Mini Clinical Evaluation Exercise (MiniCEX) 180, 183 music in operating theatres 410–11 noise in operating theatres 410–11 non-technical skills (NTS) see also Non-Technical Skills for Surgeons (NOTSS); Oxford NOTECHS system; Surgical NOTECHS anaesthesia 175–6, 186 crew resource management 67–8 nurses 68 orthopaedic surgery 335 patient safety 301 surgery 103 surgical training 7–9, 21–2 Index 453 Non-Technical Skills for Surgeons (NOTSS) 8–21, 49, 113 adverse event and mortality reviews 12–13 attitude survey 11 behavioural markers 14 critical incident reviews 13–14 development of 14–15 future research 22–3 literature review 10–11 observations 12 Procedure Based Assessments (PBAs) 44 project design 9–20 rating scale 15 system evaluation 15–17 system usability 17–20 task analysis 9–14 user handbook 17 nonroutine events (NRE) 205 N OTECH S 105 see also Non-T echnical Skills for Surgeons (NOTSS); Oxford NOTECHS system; Sur gical N OTECHS NOTSS see Non-Technical Skills for Surgeons NRE (nonroutine events) 205 NTS see non-technical skills Nurses’ NOTECHS 67–8 communication 69–70, 74 consultant surgeon interviews 77–8 decision making 72–3, 76 expert panels 78 leadership 72–3, 76 literature review 68–73 scrub nurse interviews 73 situation awareness 71–2, 76 teamwork 70–71, 74–6 Objective Structured A ssessment of Technical Skill (OSA TS) 48–9 observational methods 130–31, 263–4 Observational Teamwork Assessment for Surgery © (OTAS © ) assessment process 90–95 behaviour ratings 88, 89 development 87–8 holistic assessment 97 non-teamwork surgical processes 96 observation 113 observer’s expertise 96 Oxford NOT ECHS system 111 phases 88–9 retrospective rating 96 simulation-based team training 96 task checklist 88, 89 team feedback 89–90 team orientation 89 teamwork 84–7, 95 O CAP see Orthopaedic Competence A ssessment Project operating room see operating theatre Operating Room Management A ttitudes Questionnaire (ORMAQ) 11 operating theatre (OT) bad behaviour 446 communication 286–8 crew resource management (CRM) 155 distractions 405–15 environment 406 interruptions 405–15 music 410–11 noise 410–11 observation 387–8 prospective memory 340–41 silence 288–96 teamwork 153 telephones 334 O R see operating theatre ORM AQ (Operating Room Management Attitudes Questionnaire) 11 Orthopaedic Competence A ssessment Project (OCAP) 40, 42, 43–4 orthopaedic surgery 321–36 cases 322–3 distracters 334 dual observers 331–3 equipment 335 expert observers 335 failures 323–9, 333 index procedures 34 non-technical skills (NTS) 335 patient safety 333–5 Sur gical N OTECHS 107 teams 322–3 [...]...454 Safer Surgery telephones 334 OSATS (Objective Structured Assessment of Technical Skill) 48 9 OT see operating theatre OTAS© see Observational Teamwork Assessment for Surgery Oxford NOTECHS system 108–11 assessment of team performance 113 minor failures 112, 113 Observational Teamwork Assessment for Surgery (OTAS©) 111 technical errors 112 paediatric cardiac surgery 105–6 patient... 49–51 dichotomy 61 feasibility of tools 53–4 implementation 51, 62–3 index procedures 50 observation 50–51 participants 50 patient participants 58–9 progress to date 51 purpose of 49 reliability of tools 53 research aims 51–4 research team 54–5 sample size 50 surgical specialties 63–4 surgical trainee participants 59–60 timescale 49 validity of tools 52–3 video recording 64 Shipman Inquiry 28–9 short-term... simulation 362–4, 365 structured 132–3, 357 study methods 356–8 Surgical NOTECHS 105 orthopaedic surgery 107 Oxford NOTECHS system 108–14 paediatric cardiac surgery 105–6 scoring system 105–6 surgical pause 429 surgical performance communication 283–97 distractions 405–14 interruptions 405–14 observation of 48 9 systems approach 353–4 teamwork 83–97 video recordings 64 surgical safety programme 274–8... Teamwork Assessment for Surgery (OTAS©) 111 technical errors 112 paediatric cardiac surgery 105–6 patient safety clinical performance 223 human factors 447 non-technical skills (NTS) 301 orthopaedic surgery 333–5 surgery 151 systemic threats 321–2 teamwork 224, 399–400 time pressure 398 PBAs see Procedure Based Assessments PM see prospective memory PMETB (Postgraduate Medical Education and Training Board)... 33 surgical environment 35 surgical skill assessment 48 9 surgical task 35 trainer/trainee characteristics 35–6 validity 40 prospective memory (PM) clinical practice 349–50 definition 343 dynamic change of plans 340, 345 interruptions 341–2 phases 343–4 pilot study results 346–8 questionnaire study 346–8 recurrent measurements 339–40, 345 research 348 9 simulator study 346 treatment in time 339, 344... Skills Study see Sheffield Surgical Skills Study surgical teams disciplines 88, 431–2 teamwork 272, 274 surgical time out 429 surgical trainees training time 29, 446 workplace-based assessment 8 455 456 Safer Surgery TARGETS (Targeted Acceptable Responses to Generated Events or Tasks) 84–5 team output 398–9 teamwork adaptive coordination 224–5 anaesthesia 203–4 barriers to 154 behaviour scales 130, 132–4... 224, 399–400 surgery 95–7 surgical performance 83–97 surgical teams 153, 272, 274 sustaining 441–2 time pressure 385–400 time pressure audio-video recording 388–90 context of care 397–8 data collection 388–90, 397 patient safety 398 study methodology 387–8 subject matter experts (SME) 390 task shedding 395–6 team coordination 396–7 video analysis 390–95, 397 TKR (total knee replacement surgery) 322,... 131–2 silence 288–96 SimBaby™ 372–4 situation awareness 71–2, 76, 445–6 SME (subject matter experts) 390 stress 371–2 measurement 375–80 subject matter experts (SME) 390 surgeons, technical competence 273 surgery adverse events 151, 445 communication 273–4 complexity 446 complications 266 decision-making 353–66 effectiveness 446 error causation 103–8 leadership 445 non-technical skills 103 patient safety... 168–9 implementation 159–60, 168 pilot study 158 results 161–4 poster 156, 159–60, 166 principles 153–4 questionnaire 156–7 time out procedure 155–6, 160, 165, 166, 168–9 total knee replacement (TKR) surgery 322, 334 video recording 388–90 WHO (World Health Organization), Surgical Safety Checklist 164–5 working memory 131–2 workplace-based assessment 179–80, 189–200 World Health Organization (WHO), . to happen in real practice Safer Surgery 448 (Flin and Maran 2008). The same situation can be recreated on multiple occasions to allow observation of cohorts of participants. Although human. <www.pmetb.org.uk/reports> [last accessed March 2009]. Safer Surgery 450 Safe Surgery Saves Lives (2008) World Health Organization. Available from: <www.who.int/patientsafety/safesurgery/> [last accessed March. 107 teams 322–3 Safer Surgery 454 telephones 334 OSATS (Objective Structured Assessment of Technical Skill) 48 9 OT see operating theatre OTAS © see Observational Teamwork Assessment for Surgery © Oxford