Safer Surgery part 1 pot

Safer Surgery Edited by Rhona Flin and Lucy Mitchell Analysing Behaviour in the Operating Theatre... Safer SurgeryAnalysing Behaviour in the Operating Theatre RHONA FLIN University of A

Safer Surgery

Edited by

Rhona Flin and Lucy Mitchell

Analysing Behaviour in the Operating Theatre

SAFER SURGERY

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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 identified 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

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

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 Hofinger 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

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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, first 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 Infirmary 184 Figure 11.2 Mini CEX competency descriptors 185 Figure 12.1 Intraclass correlations calculated for each component of

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