Safer Surgery part 45 pdf

Safer Surgery 414 multi-task – i.e., to shift attentional focus from the primary task to one or more secondary tasks. Psychological research suggests that such shifts come at a cost, as performance at the primary task deteriorates (e.g., Altmann and Trafton 2007, Monsell 2003, Trafton and Monk 2008) and that different people are affected to different degrees by such demands to multi-task (e.g., Ishizaka et al. 2001). This means that some surgeons will fare better than others in coping with distracting events in the OR – an individual difference that should be assessed systematically. A nal consideration is the interaction of expertise and individual differences with the level of disruptiveness in the OR. Simply put, junior surgeons might be able to cope with an equipment failure when everything else is going smoothly in a procedure. However, if a technical problem appears jointly with an equipment failure in an OR team that does not communicate information very well, the same situation will become more stressful and the potential for impaired performance will increase. Multilayered disruptions to surgical work are likely to have an effect on performance signicantly more pronounced than the effect of individual distracting events. Question 3: Can the OR be Designed in Such a Way that Unnecessary Disruptions are Minimized? The preliminary links between distractions, stress and performance are important from a patient safety perspective. Demirtas et al. (2004, p. 929) suggested that the ‘aroused emotional state of surgeons during an operation make them more prone to make mistakes as a result of physical and mental fatigue and strain’ and concluded that surgeons may have a legal responsibility to consider the negative impact of factors such as stressors, distractions and mental strain on their performance. Distractions can greatly add to stressors that are inherent in surgery and thus signicantly increase stress by increasing demand upon the individual (see Figure 24.1). It follows that minimizing distractions in the OR environment wherever possible and/or by training surgeons in how best to cope with them when they occur is an important step towards safer surgery. Some distractions, typically those associated with equipment, cannot be anticipated. Equipment might be checked in the beginning of the operating list and still fail unexpectedly. Adequate planning (part of efcient teamwork in the OR and potentially enhanced using simple interventions, such as an equipment checklist), however, should allow quick replacement and minimize disruption to the operative process. Other distractions are more amenable to control. Number of visitors in the OR can be reduced, phones/bleepers could be left outside the OR and answered by a oating member of staff, who can lter the information for urgency and decide whether the surgeon, or any other team member, should be interrupted. Vincent et al. (2006) and Bates (2000) have commented that most healthcare processes were not designed; instead, they evolved. Socio-technically complex, the OR is a workspace that could potentially benet from evidence-base design, with user input (e.g., Reiling et al. 2004). Importantly, smaller- and larger- Distraction and Interruptions in the Operating Room 415 scale design intervention should be evaluated for efcacy in reducing overall level of disruption and enhancing the ow of the surgical process (Campbell et al. 2000). Acknowledgements This chapter is based on an ongoing research programme on safety implications of the surgical environment that is being carried out by our research group. Dr Andrew N. Healey, former member of the group, played an instrumental role in the shaping and development of this work since its inception and over a number of years. The authors would like to thank the Department of Health: Patient Safety Research Programme (CAV), the BUPA Foundation (CAV), the Smith and Nephew foundation (CAV), the Engineering and Physical Sciences Research Council (EPSRC) (CAV), and the Economic and Social Research Council (ESRC) Centre for Economic Learning and Social Evolution (NS) for providing funding for the work reported in this chapter. References Altmann, E.M. and Trafton, J.G. (2007) Timecourse of recovery from task interruption: Data and a model. Psychonomic Bulletin and Review 14, 1079– 84. Figure 24.1 The distractions–stress ladder (Multiple) Distractions Phones/bleeps Equipment Requests Demands outweigh resources Increased stress Increased demand Safer Surgery 416 Aggarwal, R., Moorthy, K. and Darzi, A. (2004) Laparoscopic skills training and assessment. British Journal of Surgery 91, 1549–58. Aggarwal, R., Balasundaram, I. and Darzi, A. (2008) Training opportunities and the role of virtual reality simulation in acquisition of basic laparoscopic skills. Journal of Surgical Research 145, 80–6. Alvarez, G. and Coiera, E. (2005) Interruptive communication patterns in the intensive care unit ward round. International Journal of Medical Informatics 74, 791–6. Arora, S., Sevdalis, N., Nestel, D., Tierney, T., Woloshynowych, M. and Kneebone, R. (2009) Managing intra-operative stress: What do surgeons want from a crisis training program? American Journal of Surgery, 197, 537–543. Bates, D.W. (2000) Using information technology to reduce rates of medication errors in hospitals. British Medical Journal 320, 788–91. Brixey, J.J., Tang, Z., Robinson, D.J., Johnson, C.W., Johnson, T.R., Turley, J.P., Patel, V.L. and Zhang, J. (2008) Interruptions in one trauma center: A case study. International Journal of Medical Informatics 77, 235–41 Cabrera, I.N., and Lee, M.H. 2000. Reducing noise pollution in the hospital setting by establishing a department of sound: A survey of recent research on the effects of noise and music in health care. Preventive Medicine 30, 339–45. Calland, J.F., Guerlain, S., Adams, R.B., Tribble, C.G., Foley, E. and Chekan, E.G. (2002) A systems approach to surgical safety. Surgical Endoscopy 16, 1005–14. Campbell, M., Fitzpatrick, R., Haines, A., Kinmonth, A.L., Sandercock, P., Spiegelhalter, D. and Tyrer P. (2000) Framework for design and evaluation of complex interventions to improve health. British Medical Journal 321, 694–6. Chisholm, C.D., Dornfeld, A.M., Nelson, D.R. and Cordell, W.H. (2001) Work interrupted: A comparison of workplace interruptions in emergency department and primary care ofces. Annals of Emergency Medicine 38, 146–51. Coiera, E. and Tombs, V. (1998) Communication behaviours in a hospital setting: An observational study. British Medical Journal 316, 673–7. Dankelman, J. and Di Lorenzo, N. (2005) Surgical training and simulation. Minimally Invasive Therapy and Allied Technologies 14, 211–13. Demirtas, Y., Tulmac, M., Yavuzer, R., Yalcin, R., Ayhan, S., Latifoglu, O. and Atabay, K. (2004) Plastic surgeon’s life: Marvellous for mind, exhausting for body. Plastic and Reconstructive Surgery 114, 923–31. Gawande, A.A., Zinner, M.J., Studdert, D.M. and Brennan, T.A. (2003) Analysis of errors reported by surgeons at three teaching hospitals. Surgery 133, 614– 21. Goodell, K.H., Cao, C.G.L. and Schwaitzberg, S.D. (2006) Effects of cognitive distraction on performance on laparoscopic tasks. Journal of Laparoendoscopic and Advanced Surgical Techniques 16, 94–8. Greenberg, C.C., Regenbogen, S.E., Studdert, D.M., Lipsitz, S.R., Rogers, S.O., Zinner, M.J. and Gawande, A.A. (2007) Patterns of communication breakdowns Distraction and Interruptions in the Operating Room 417 resulting in injury to surgical patients. Journal of the American College of Surgeons 204, 533–40. Hassan, I., Weyers, P., Maschuw, K., Dick, B., Gerdes, B., Rothmund, M. and Zielke, A. (2006) Negative stress-coping strategies among novices in surgery correlate with poor virtual laparoscopic performance. British Journal of Surgery 93, 1554–9. Hawksworth, C.R., Asbury, A.J. and Millar, K. (1997) Music in theater: Not so harmonious. A survey of attitudes to music played in the operatic theater. Anaethesia 52, 79–83. Hawksworth, C.R., Sivalingam, P. and Asbury, A.J. (1998) The effect of music on anaesthetists’ psychomotor performance. Anaethesia 53, 195–7. Healey, A.N. and Vincent, C. (2007) The systems of surgery. Theoretical Issues in Ergonomic Science 8, 429–43. Healey, A.N., Sevdalis, N. and Vincent, C.A. (2006) Measuring intra-operative interference from distraction and interruption observed in the operating theatre. Ergonomics 49, 589–604. Healey, A.N., Primus, C.P. and Koutantji M. (2007) Quantifying distraction and interruption in urological surgery. Quality and Safety in Health Care 16, 135– 9. Hodge, B. and Thompson, J.F. (1990) Noise pollution in the operating theatre. Lancet 335, 891–4. Hsu, K.E., Man, F.Y., Gizicki, R.A., Feldman, L.S. and Fried, G.M. (2008) Experienced surgeons can do more than one thing at a time: Effect of distractions on performance of a simple laparoscopic and cognitive task by experienced and novice surgeons. Surgical Endoscopy 22, 196–201. Ishizaka, K., Marshall, S.P. and Conte, J.M. (2001) Individual differences in attentional strategies in multitasking situations. Human Performance 14, 339– 58. Issenberg, S., Gordon, M.S., Gordon, D.L., Safford, R.E. and Hart, I.R. (2001) Simulation and new learning technologies. Medical Teacher 16, 16–23. Miskovic, D., Rosenthal, R., Zingg, U., Oertli, D., Metzger, U. and Jancke, L. (2008) Randomised controlled trial investigating the effect of music on the virtual reality laparoscopic learning performance of novice surgeons. Surgical Endoscopy 22, 2416–20. Monsell, S. (2003) Task switching. Trends in Cognitive Science 7, 134–40. Moorthy, K., Munz, Y., Dosis, A., Bann, S. and Darzi, A. (2003) The effect of stress-inducing conditions on the performance of a laparoscopic task. Surgical Endoscopy 17, 1481–4. Moorthy, K., Munz, Y., Undre, S. and Darzi, A. (2004) Objective evaluation of the effect of noise on the performance of a complex laparoscopic task. Surgery 136, 25–30. Murthy, V.S.S.N., Mlhotra, S.K., Bala, I. and Raghunathan, M. (1995) Detrimental effects of noise on anaesthetists. Canadian Journal of Anaesthesia 42, 608– 11. Safer Surgery 418 Primus, C.P., Healey, A.N. and Undre, S. (2007) Distraction in the urology operating theatre. BJU International 99, 493–4. Reiling, J.G., Knutzen, B.L., Wallen, T.K., McCullough, S., Miller, R. and Chernos, S. (2004) Enhancing the traditional hospital design process: A focus on patient safety. Joint Commission Journal on Quality and Patient Safety 3, 1–10. Royal College of Surgeons of England (2007) Safe Shift Working for Surgeons in Training: Revised Policy Statement from the Working Time Directive Working Party. London: Royal College of Surgeons of England Saegert, S. and Winkel, G.H. (1990) Environmental psychology. Annual Review of Psychology 41, 441–77. Schuetz, M., Gockel, I., Beardi, J., Hakman, P., Dunschede, F., Moenk, S., Heinrichs, W. and Junginger, T. (2008) Three different types of surgeon-specic stress reactions identied by laparoscopic simulation in a virtual scenario. Surgical Endoscopy 22, 1263-7. Shapiro, K.A. and Berland, T. (1972) Noise in the operating room. New England Journal of Medicine 287, 1236–8. Sevdalis, N., Healey, A.N. and Vincent, C.A. (2007) Distracting communications in the operating theatre. Journal of Evaluation in Clinical Practice 13, 390–4. Sevdalis, N., Forrest, D., Undre, S., Darzi, A. and Vincent, C.A. (2008) Annoyances, disruptions, and interruptions in surgery: The Disruptions in Surgery Index (Disi). World Journal of Surgery 32, 1643–50. Sundstrom, E., Bell, P.A., Busby, P.L. and Asmus, C. (1996) Environmental psychology 1989–1994. Annual Review of Psychology 47, 485–512. Trafton, J.G. and Monk, C.M. (2008) Task interruptions. In D.A. Boehm-Davis (ed.), Reviews of Human Factors and Ergonomics, Volume 3 (pp. 111–26). Santa Monica, CA: Human Factors and Ergonomics Society. Undre, S., Sevdalis, N., Healey, A.N., Darzi, A. and Vincent, C.A. (2006a) Teamwork in the operating theatre: Cohesion or confusion? Journal of Evaluation in Clinical Practice 12, 182–9. Undre, S., Healey, A.N., Darzi, A. and Vincent C.A. (2006b) Observational assessment of surgical teamwork: A feasibility study. World Journal of Surgery 30, 1774–83. Undre, S., Sevdalis, N., Healey, A.N., Darzi, A. and Vincent, C.A. (2007a) Observational teamwork assessment for surgery (OTAS): Renement and application in urological surgery. World Journal of Surgery 31, 1373–81. Undre, S., Koutantji, M., Sevdalis, N., Gautama, S., Selvapatt, N., Williams, S., Sains, P., McCulloch, P., Darzi, A. and Vincent, C.A. (2007b) Multidisciplinary crisis simulations: The way forward for training surgical teams. World Journal of Surgery 31, 1843–53. Verdaasdonk, E.G.G., Stassen, L.P.S., van der Elst, M., Karsten, T.M. and Dankelman, J. (2007) Problems with equipment during laparoscopic surgery. Surgical Endoscopy 21, 275–9. Distraction and Interruptions in the Operating Room 419 Verdaasdonk, E.G.G., Stassen, L.P.S., Hoffman, W.F., van der Elst, M. and Dankelman, J. (2008) Can a structured checklist prevent problems with laparoscopic equipment? Surgical Endoscopy 22, 2238–43. Vincent, C., Moorthy, K., Sarker, S. K., Chang, A. and Darzi, A.W. (2004) Systems approaches to surgical quality and safety: From concept to measurement. Ann. Surg. 239(4), 475–82. Vincent, C.A., Lee, A.C.H. and Hanna, G.B. (2006) Patient safety alerts: A balance between evidence and action. Archives of Disease in Childhood Fetal and Neonatal Edition 91, 314–15. Wetzel, C.M., Kneebone, R.L., Woloshynowych, M., Nestel, D., Moorthy, K., Kidd, J. and Darzi, A. (2006) The effects of stress on surgical performance. American Journal of Surgery 191, 5–10. Wiegmann, D.A., ElBardissi, A.W., Dearani, J.A., Daly, R.C., and Sundt, T.M. (2007). Disruptions in surgical ow and their relationship to surgical errors: An exploratory investigation. Surgery 142, 658–65. Yule, S., Flin, R., Paterson-Brown, S. and Maran, N. (2006) Non-technical skills for surgeons. A review of the literature. Surgery 139, 140–9. Yule, S., Flin, R., Maran, N., Rowley, D.R., Youngson, G.G. and Paterson-Brown, S. (2008) Surgeons’ non-technical skills in the operating room: Reliability testing of the NOTSS behaviour rating system. World Journal of Surgery 32, 548–56. This page has been left blank intentionally Part IV Discussions This page has been left blank intentionally Chapter 25 Putting Behavioural Markers to Work: Developing and Evaluating Safety Training in Healthcare Setting s David Musson Introduction Like others in this book, the impetus to write this chapter came from a meeting that was held in Edinburgh in 2007 that brought together some of us who were active or interested in research aimed at understanding and improving the performance of teams in the operating room (or the operating theatre, as my friends in the United Kingdom would say). As I sat listening to colleagues from Europe and North America describe their excellent work in dening and training non-technical skills, I was left with a nagging sense that we were missing something important. Although I had started my career in medicine, I had spent many of the last 15 years immersed in aviation safety – rst in the Canadian Air Force, and more recently at the University of Texas at Austin studying under, then working alongside, Bob Helmreich, with whose work some readers are likely familiar. Arriving in Austin in 1998, I had essentially parachuted into the world of CRM – crew resource management. Crew resource management is the term that has been given to training programmes developed within the aviation world to teach or train commercial and military pilots in human factors, leadership and crew management with the ultimate goal of improving ight safety. As a physician landing in one of the major CRM research groups in the world, it took some time to adjust to the differences in the ways my new colleagues looked at teamwork and the way I had been used to thinking of it in medicine. It would have been fair to say that I was not used to thinking about teamwork at all, but rather was comfortable looking at performance in terms of individual (or more specically my own) competence in what I now realized were team settings. I do not think I was unique in that sense, and in fact my impression since that time has been that most physicians are worried about, rst and foremost, their own competence. Indeed, one can argue that individual practitioner competence has long been perceived as the fundamental cornerstone of quality medical care. It is why medical schools are supposed to be difcult to get into, and why medical school curricula are typically challenging and the study load demanding. It is also why the training hours are long and arduous, and why current efforts to reduce those hours are sometimes . resources Increased stress Increased demand Safer Surgery 416 Aggarwal, R., Moorthy, K. and Darzi, A. (2004) Laparoscopic skills training and assessment. British Journal of Surgery 91, 1549–58. Aggarwal,. task. Surgery 136, 25–30. Murthy, V.S.S.N., Mlhotra, S.K., Bala, I. and Raghunathan, M. (1995) Detrimental effects of noise on anaesthetists. Canadian Journal of Anaesthesia 42, 608– 11. Safer Surgery 418 Primus,. Vincent, C.A. (2008) Annoyances, disruptions, and interruptions in surgery: The Disruptions in Surgery Index (Disi). World Journal of Surgery 32, 1643–50. Sundstrom, E., Bell, P.A., Busby, P.L. and