Safer Surgery 314 Quality of Communication in Critical Situations Quality of Communication as Evaluated by the Behavioural Markers How well do the participants full the expectations concerning good communication that we formulated as behavioural markers? The number of behavioural markers conrmed in the utterances of each participant showed a rather weak performance. In fact, only 58 percent of the expected behaviours were shown (with an inter-rater reliability of 83 percent). For example, in 61 percent of all scenarios, the anaesthetists did not explicitly seek agreement with the surgeon (we also repeatedly found this in OR observations) before important steps in the process. Clinical Experience and Quality of Communication What role does clinical experience play in the quality of communication? Based on our observations in the OR, we expected that senior anaesthetists would not necessarily perform better because simply working longer in the setting ‘hospital’ does not seem to imply learning more about good communication. This was exactly what we found when looking at the behavioural markers. Communication Skills and the Quality of Medical Problem Solving Based on the literature on human factors, we expected a substantial correlation between the evaluation of medical management and the quality of communication, as captured in the behavioural markers. We found a surprisingly high correlation of r=.57 (p=.001; t=3.77; df=31; see Figure 18.1). Those doctors who communicated most adequately also performed best. Interestingly, the quality of medical management is not connected with the total number of things said (r= 08; p>.1). Talking a lot during a medical crisis is not useful in itself; what is important is the quality of communication. Category Thematization of the relationship Reflection/ emotional utterances Process Total Mean 5.5 2.9 12.2 20.5 Minimum 0 0 1 4 Maximum 22 10 32 47 Table 18.7 Utterances related to the team and the problem-solving process Observing Team Problem Solving and Communication in Critical Incidents 315 The Inuence of Establishing Shared Mental Models on the Quality of Medical Management Is there a connection between the quality of medical management and the establishment of shared mental models, as found in the categories spontaneously addressing the surgeon; conrming understanding; conveying problems with explanation; explanation of one’s own activity? For the entire ‘package’ of variables relevant to this question, correlation is zero (r=.09; p>.1). Because the literature (see above) postulates the importance of the establishment of shared mental models – a judgement we share – we examined the individual correlations. In our scenarios, utterances directed primarily to the nursing staff (conrming understanding; explanation of one’s own activity) did not signicantly contribute to effectiveness of the doctor’s problem solving (r=.20; p>.1 and r=.09; p>.1). Nevertheless, this kind of utterance remains important for patient safety. The case is different for conveying problems with explanation, a behaviour usually directed at the surgeon; here, the assumed importance of a shared understanding of the situation is found (r=.25; p=.045). Telling a problem and giving explanations allows the team partner to think along the same lines. Discussion and Outlook The ndings presented in this chapter suggest that it is possible to investigate and analyse the content of the communication of anaesthesiologists in (simulated) critical situations. Substantial portions of spoken communication serve the problem-solving regulation of activity and the coordination of the team. Figure 18.1 Connection between medical management and the quality of communication 0 0,2 0,4 0,6 0,8 1 1,2 0 0,2 0,4 0,6 0,8 1 1,2 Medical management Communication (% of behavioural markers found in participant's utterances) Behavioural markers Safer Surgery 316 Several factors limit this approach. First, despite the similarity of the setting, an incident in the simulator differs emotionally and medically from an incident in an actual operation – the genuine danger and the genuine support are both lacking. Second, communication during an operation is not solely verbal – coordination of actions is also achieved implicitly often by gesture and especially by expressions of the eyes, which impress observers with their differentiation. Nevertheless, the spoken word is indispensable and essential for common activity on the basis of shared mental models, including during an operation. What can be deduced from the presented results for specialized training and advanced training? First, we can conrm that communication is indeed important for managing incidents in anaesthesiology. The high correlation between the quality of medical management and the quality of communication permits us to conclude that good communication alone cannot, of course, produce a good physician, but it helps in nding strategies for successful problem-solving activity in critical, i.e., medically dangerous, situations. Expressed negatively: poor communication prevents, among other things, the securing of adequate support in medically overchallenging situations. Also of course, (medical) overburdening favours poor communication. But anaesthesiologists’ abilities to express problem solving and team coordination in communication differ very widely. There is a marked need for improvement. The behaviour data thus support the need to include more non- technical skills in professional and advanced training as seen in the literature presented in the introduction. 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This page has been left blank intentionally Chapter 19 Observing Failures in Successful Orthopaedic Surgery Ken Catchpole Introduction It is becoming increasingly recognized from accidents in a range of high-risk industries that small and recurrent failures, deriving from or predisposed by deciencies in system function, can accumulate to create a catastrophic event (Fennell 1998, Gaba 1989, Helmreich 1994, Kennedy 2001, Lawton and Ward 2005). Surgery sits at the apex of the healthcare service, which makes it ideal for understanding both human error and the systemic properties that predispose error, since the sources of problems observed inside the operating theatre can often be attributed to decient elements of the system. Success depends upon the pre- operative work-up, team coordination and appropriate equipment (Cook and Woods 1996), and also requires an organization and culture which support the progress of the patient through their treatment, and the activities of the team in the operating theatre (Kirklin et al. 1992). A sequence of human factors studies in paediatric cardiac surgery based on the structured post-hoc analysis of free-form notes made by expert observers found that seemingly innocuous intra-operative problems could accumulate to affect the outcome for the patients (de Leval et al. 2000b) and were more likely to create a serious risk in longer, more complex operations (Catchpole et al. 2006). Given that cardiac paediatric surgery is complex, high risk and relatively rare, it may not be representative of most operations, so we sought to identify properties of surgical systems that predispose errors in a routine, higher volume, lower risk surgery. Observing small, recurrent problems in the operating theatre makes it possible to identify prospectively latent failures within the system which are regularly mitigated for, but occasionally cause harm. This prospective identication of weak points in the system has three important advantages; it is resistant to hindsight bias, which often aficts the response to catastrophic failure (Berlin 2000, Fischhoff 1975, Woods and Cook 1999); it can help to build defences before adverse events occur (Carthey et al. 2001, Cook and Woods 1994); and by rectifying frequent problems, it may also improve the efciency of surgery. We built on previous attempts to study systemic threats to patient safety (Helmreich 2000, Kaplan et al. 1998, Vincent et al. 1998), by attempting to identify the common causes of a larger number of observable problems. For our work in paediatric cardiac surgery, we Safer Surgery 322 had previously developed an analysis technique referred to as the failure source model (Catchpole et al. 2006, Catchpole et al. 2008), which provided a weighting network for each failure based on the source of the problems, and allowed systematic distinction between human errors in the operating theatre and aspects of the patient, task, environment (which included equipment and workspace), organization and culture that predisposed those errors before the operation. This made it possible to develop a prole of the different systemic contributions to problems during the course of an operation, reinforcing the view that human errors might be avoided and providing a semi-objective evaluation of where the most frequently encountered systemic problems lay. Total knee replacement (TKR) surgery is an elective and proceduralized operation usually involving two surgeons, an anaesthetist, a scrub nurse, a circulating nurse and an anaesthetic nurse. There are two basic types; the rst insertion of a knee prosethetic, known as a primary TKR (Table 19.1); and the replacement of an existing prosthetic, known as a TKR revision. This latter operation is less frequent, more complex, more unpredictable, higher risk and requires a larger array of instruments than a primary TKR. We aimed to: conrm that the escalation from small problems to serious risk was inuenced by complexity; examine further the collection of human errors and systemic predisposition of error; and apply the failure source model technique to reinforce the view that errors in surgery are avoidable by systemic redesign. By comparing the results of two observers – one with a human factors background and experience in the operating theatre; the other who had previously worked in the operating theatre and had training in human factors – in multiple TKR cases, it was also possible to explore the reliability of this semi-quantitative, free-form observational technique. Case and Team Mix Fourteen cases carried out under one consultant orthopaedic surgeon were studied by dual observers in a single operating theatre at a large UK hospital. The rst surgeon was always the consultant or his specialist registrar. All 18 operations featured the same anaesthetist, and the scrub nurse and circulating nurses came from a pool of four individuals who regularly interchanged roles. This meant that while the team composition was not always identical, operations usually featured the same individuals, often in the same roles. Ten operations were TKR operations and four were revisions of a TKR. Prosthetic implants from a range of manufacturers were studied. Mean operative duration was 107.8 mins (95 percent • • • Observing Failures in Successful Orthopaedic Surgery 323 C.I. ± 26.3), and mean tourniquet time was 115.6 mins (95 percent C.I. ± 17.2). The patients ranged from 60 to 84 years of age. All operations were successful, and no observed failure was deemed worthy of further investigation either by the individuals involved, or by the hospital. Method for Identifying Minor and Major Failures To prepare for the observations, ten similar cases were studied by both researchers before data collection began, and a task analysis and procedural-based error- capture checklists were produced for TKR operations (Catchpole et al. 2005). This checklist allowed structured error-capture observations, and included over 100 items and 17 time-marker events. However, since they did not capture all the salient events, it was also necessary during data collection to make detailed notes of activities and communications, which produced descriptions of events in theatre and the time and sequence in which those events occurred. In all 14 cases a video recording was made of the operating theatre from two views, one at the head of the table, looking toward the surgical eld from behind the anaesthetist, and one on the left-hand side of the patient, utilizing a wide-angle lens to record the scrub nurse, surgeons and surgical eld, and the anaesthetist Key phases in the total knee replacement operation The total knee replacement operation replaces damaged and painful knee joints with a completely articial joint prosthesis. 1. The patient is anaesthetized in the anaesthetic room which adjoins the operating theatre. 2. The patient is transferred to operating table in the operating theatre. 3. The treatment site is cleaned, and a tourniquet is applied to the thigh to be treated. 4. The rst incision is made, and carried to the knee capsule. 5. The knee is dislocated, and an intra-medullary rod inserted to x the femoral cutting block. 6. The femur is cut distally with an oscillating saw. Following appropriate sizing, a second cutting block is used to make anterior posterior and chamfer cuts. 7. The tibial cut is made following alignment with the lower leg, and conguration of the tibial cutting block. 8. T rial tibial and femoral prostheses are used to test the t and conrm sizing of the implant. 9. The patella is re-surfaced if required. 10. Cement is prepared and applied to tibial and femoral prosthetic components, which are rmly seated. The leg is again checked for t. 11. Once the cement has cured, the wound is washed and closed. 12. The tourniquet is removed, tourniquet time is recorded, and the patient is transferred to the recovery suite. Table 19.1 Phases of a typical primary total knee replacement operation . Safer Surgery 314 Quality of Communication in Critical Situations Quality of Communication as Evaluated by the Behavioural Markers How well do the participants full the. 1,2 Medical management Communication (% of behavioural markers found in participant's utterances) Behavioural markers Safer Surgery 316 Several factors limit this approach. First, despite the. causes of a larger number of observable problems. For our work in paediatric cardiac surgery, we Safer Surgery 322 had previously developed an analysis technique referred to as the failure