Safer Surgery part 1 pot

Safer Surgery Edited by Rhona Flin and Lucy Mitchell Analysing Behaviour in the Operating Theatre SAFER SURGERY This page has been left blank intentionally Safer Surgery Analysing Behaviour in the Operating Theatre RHONA FLIN University of Aberdeen, UK & LUCY MITCHELL University of Aberdeen, UK © Rhona Flin and Lucy Mitchell 2009 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior permission of the publisher. Rhona Flin and Lucy Mitchell have asserted their moral right under the Copyright, Designs and Patents Act, 1988, to be identied as the authors of this work. Published by Ashgate Publishing Limited Ashgate Publishing Company Wey Court East Suite 420 Union Road 101 Cherry Street Farnham Burlington Surrey, GU9 7PT VT 05401-4405 England USA www.ashgate.com British Library Cataloguing in Publication Data Safer surgery : analysing behaviour in the operating theatre. 1. Surgical errors Prevention. 2. Operating room personnel Psychology. 3. Operating room personnel Evaluation. 4. Teams in the workplace. 5. Surgical errors. I. Flin, Rhona H. II. Mitchell, Lucy. 617.9-dc22 ISBN: 978-0-7546-7536-5 (hbk); 978-0-7546-9577-6 (ebk.II) Library of Congress Cataloging-in-Publication Data Safer surgery : analysing behaviour in the operating theatre / [edited] by Rhona Flin and Lucy Mitchell. p. cm. Includes bibliographical references and index. ISBN 978-0-7546-7536-5 1. Surgical errors Prevention. 2. Surgery. 3. Operating rooms. I. Flin, Rhona H. II. Mitchell, Lucy. [DNLM: 1. Medical Errors prevention & control. 2. Surgical Procedures, Operative- -methods. 3. Accident Prevention. 4. Interprofessional Relations. 5. Operating Rooms. WO 500 S128 2009] RD27.85.S24 2009 617 dc22 2009004030 Contents List of Figures ix List of Tables xi Notes on Contributors xiii Foreword by Charles Vincent xxiii Preface by George Youngson xxv 1 Introduction 1 Rhona Flin and Lucy Mitchell PART I TOOLS FOR MEASURING BEHAVIOUR IN THE OPERATING THEATRE 2 Development and Evaluation of the NOTSS Behaviour Rating System for Intraoperative Surgery (2003–2008) 7 Steven Yule, Rhona Flin, Nikki Maran, David Rowley, George Youngson, John Duncan and Simon Paterson-Brown 3 Competence Evaluation in Orthopaedics – A ‘Bottom-up’ Approach 27 David Pitts and David Rowley 4 Implementing the Assessment of Surgical Skills and Non-Technical Behaviours in the Operating Room 47 Joy Marriott, Helen Purdie, Jim Crossley and Jonathan Beard 5 Scrub Practitioners’ List of Intra-Operative Non-Technical Skills – SPLINTS 67 Lucy Mitchell and Rhona Flin 6 Observing and Assessing Surgical Teams:The Observational Teamwork Assessment for Surgery © (OTAS) © 83 Shabnam Undre, Nick Sevdalis and Charles Vincent 7 Rating Operating Theatre Teams – Surgical NOTECHS 103 Ami Mishra, Ken Catchpole, Guy Hirst, Trevor Dale and Peter McCulloch Safer Surgery vi 8 RATE: A Customizable, Portable Hardware/Software System for Analysing and Teaching Human Performance in the Operating Room 117 Stephanie Guerlain and J. Forrest Calland 9 A-TEAM: Targets for Training, Feedback and Assessment of all OR Members’ Teamwork 129 Carl-Johan Wallin, Leif Hedman, Lisbet Meurling and Li Felländer-Tsai 10 Introducing TOPplus in the Operating Theatre 151 Connie Dekker-van Doorn, Linda Wauben, Benno Bonke, Geert Kazemier, Jan Klein, Bianca Balvert, Bart Vrouenraets, Robbert Huijsman and Johan Lange PART II OBSERVATIONAL STUDIES OF ANAESTHETICS 11 Integrating Non-Technical Skills into Anaesthetists’ Workplace-based Assessment Tools 175 Ronnie Glavin and Rona Patey 12 Using ANTS for Workplace Assessment 189 Jodi Graham, Emma Giles and Graham Hocking 13 Measuring Coordination Behaviour in Anaesthesia Teams During Induction of General Anaesthetics 203 Michaela Kolbe, Barbara Künzle, Enikö Zala-Mezö, Johannes Wacker and Gudela Grote 14 Identifying Characteristics of Effective Teamwork in Complex Medical Work Environments: Adaptive Crew Coordination in Anaesthesia 223 Tanja Manser, Steven K. Howard and David M. Gaba 15 Teams, Talk and Transitions in Anaesthetic Practice 241 Andrew Smith, Catherine Pope, Dawn Goodwin and Maggie Mort PART III OBSERVATION OF THEATRE TEAMS 16 An Empiric Study of Surgical Team Behaviours, Patient Outcomes, and a Programme Based on its Results 261 Eric Thomas, Karen Mazzocco, Suzanne Graham, Diana Petitti, Kenneth Fong, Doug Bonacum, John Brookey, Robert Lasky and Bryan Sexton Contents vii 17 Counting Silence: Complexities in the Evaluation of Team Communication 283 Lorelei Lingard, Sarah Whyte, Glenn Regehr and Fauzia Gardezi 18 Observing Team Problem Solving and Communication in Critical Incidents 301 Gesine Honger and Cornelius Buerschaper 19 Observing Failures in Successful Orthopaedic Surgery 321 Ken Catchpole 20 Remembering To Do Things Later and Resuming Interrupted Tasks: Prospective Memory and Patient Safety 339 Peter Dieckmann, Marlene Dyrløv Madsen, Silke Reddersen, Marcus Rall and Theo Wehner 21 Surgical Decision-Making: A Multimodal Approach 353 Nick Sevdalis, Rosamond Jacklin and Charles Vincent 22 Simulator-Based Evaluation of Clinical Guidelines in Acute Medicine 371 Christoph Eich, Michael Müller, Andrea Nickut and Arnd Timmermann 23 Measuring the Impact of Time Pressure on Team Task Performance 385 Colin F. Mackenzie, Shelly A. Jeffcott and Yan Xiao 24 Distractions and Interruptions in the Operating Room 405 Nick Sevdalis, Sonal Arora, Shabnam Undre and Charles Vincent PART IV DISCUSSIONS 25 Putting Behavioural Markers to Work: Developing and Evaluating Safety Training in Healthcare Settings 423 David Musson 26 Commentary and Clinical Perspective 437 Paul Uhlig 27 Behaviour in the Operating Theatre: A Clinical Perspective 445 Nikki Maran and Simon Paterson-Brown Index 451 This page has been left blank intentionally List of Figures Figure 2.1 Developing the NOTSS system 10 Figure 2.2 NOTSS skills taxonomy v1.2 17 Figure 2.3 Completed NOTSS rating form 19 Figure 3.1 Total hip replacement PBA T&O curriculum 32 Figure 4.1 Flowchart of the study implementation 52 Figure 7.1 Escalation model of surgical error 104 Figure 7.2 Relationship between minor failures and ranked non-technical skills performance in paediatric cardiac surgery 107 Figure 7.3 Mechanisms of surgical failure 108 Figure 7.4 Oxford NOTECHS scores against OTAS scores for 5 LCs 111 Figure 8.1 The RATE software 124 Figure 8.2 The RATE event-marking software 125 Figure 9.1 A schematic presentation of a structured team decision- making process 133 Figure 10.1 Causes for latent failures leading to adverse events 152 Figure 10.2 TOPplus poster, rst version tested during pilot 159 Figure 10.3 Questions asked by team members as indicated on the poster 161 Figure 10.4 Answers given by the team members as indicated on the poster 162 Figure 10.5 Final version of the poster 167 Figure 11.1 Mini CEX trainee assessment, Victoria Inrmary 184 Figure 11.2 Mini CEX competency descriptors 185 Figure 12.1 Intraclass correlations calculated for each component of ANTS 196 Figure 13.1 A taxonomy of explicit and implicit team coordination and heedful interrelating behaviour 210 Figure 14.1 Conceptual framework of adaptive collaborative practice 226 Figure 14.2 Overview of the observation system for coordination behaviour in anaesthesia crews 229 Figure 14.3 System for data recording: FIT-system (left) and template with observation codes including ‘buttons’ for members of the operating room team (right) 230 . 16 7 Figure 11 .1 Mini CEX trainee assessment, Victoria Inrmary 18 4 Figure 11 .2 Mini CEX competency descriptors 18 5 Figure 12 .1 Intraclass correlations calculated for each component of ANTS 19 6 Figure. paediatric cardiac surgery 10 7 Figure 7.3 Mechanisms of surgical failure 10 8 Figure 7.4 Oxford NOTECHS scores against OTAS scores for 5 LCs 11 1 Figure 8 .1 The RATE software 12 4 Figure 8.2 The. during pilot 15 9 Figure 10 .3 Questions asked by team members as indicated on the poster 16 1 Figure 10 .4 Answers given by the team members as indicated on the poster 16 2 Figure 10 .5 Final version