Safer Surgery part 2 pps

Her research interests include surgical education and training for patient safety, with a focus upon simulation and non-technical skills training.. doug.bonacum@kp.org Benno Bonke is an

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Figure 16.1 The predicted relationship between Behavioral Marker

Risk Index and post-operative complications and

Figure 18.1 Connection between medical management and the quality

Figure 19.1 Video equipment configuration for orthopaedic surgery

324 Figure 19.2 Mean number of minor failures per operation by type 328 Figure 19.3 Failure source model which links observable minor

failures (small boxes) and common systemic causes

Figure 19.4 Mean rates of threats (top panel) and errors (bottom

panel), with 95 percent confidence intervals 331 Figure 19.5 Bland-Altman plot for agreement between two

Figure 21.1 A model for the study, with the cues that were available

Figure 21.2 Cue utilization across individual surgeons 362 Figure 22.1 Study setting in theatres: infant simulator and anaesthesia

work station, anaesthesia nurse (left) and candidate (right) with the mobile ergospirometry unit applied 373 Figure 22.2 Flow chart for simulated scenario and stress

Figure 22.4 Candidate with mobile and wireless ergospirometry

Figure 22.5 Salivary cortisol levels during stress (Trier Social Stress

Test, TSST) and rest conditions (Nater et al 2006) 378 Figure 22.6 Salivary alpha-amylase and norepinephrine (noradrenaline)

in response to stress (Trier Social Stress Test,

Figure 23.1 Ambulatory electrocardiograms (ECG) and blood pressure

(BP) of an anaesthesiologist during elective (top panel) and emergency (lower panel) intubations 391 Figure 23.2 Heart rate (HR) and blood pressure (BP) of an experienced

anaesthesiologist obtained by ambulatory monitors

Figure 23.3 Comparison of task omission (among those tasks shown

Figure 24.1 The distractions–stress ladder 415 Figure 25.1 An iceberg model for observed behaviours 431

Table 2.1 Summary of NOTSS v1.1 evaluation results 16

Table 3.2 Example elements for total hip replacement PBA, taken

Table 3.3 Global assessment taken from T&O curriculum 33 Table 3.4 Validation worksheet example taken from T&O curriculum 41 Table 4.1 Index procedures within the surgical specialties 50 Table 5.1 Non-technical skill categories examined in the 13

Table 5.2 Examples of scrub nurse interview questions 73 Table 5.3 Interviewee responses categorized as communication 75 Table 6.1 Operative phases and stages of OTAS© 88 Table 6.2 Task completion rates in general surgery (first study)

versus urology (second study) 91 Table 7.1 Summary of first iteration of the surgical NOTECHS

Table 7.2 Reliability (Rwg) of Oxford NOTECHS tool for 36 dual

Table 7.3 Reliability (Rwg) of Oxford NOTECHS for 12 dual

Table 7.4 Reliability of Oxford NOTECHS in 14 cases observed

independently with third observer 110 Table 9.1 The A-TEAM scale for assessment of individual team

Table 10.1 Overview questionnaire communication and teamwork

Table 10.3 Duration of the time out (in seconds) 163 Table 10.4 Duration of the debriefing (in seconds) 163 Table 11.1 The ANTS system: categories and elements 177 Table 13.1 Definitions and examples for categories 211 Table 14.1 Intra-observer agreement over time for the observation

system reported at the level of observation categories 231 Table 16.1 Description of domains behavioural markers of team

behaviour assessed by the observers 264 Table 16.2 Definitions of measures: patient risk of complications

(American Society of Anesthesiologists – ASA – classification), procedure risk (American College of Cardiologists – ACC-score) and outcome (outcome score) 265

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Table 16.3 Characteristics of 293 patients and procedures 268 Table 16.4 Description of behavioural markers scores by operative phase,

number and percentage of procedures with complication

or death, and odds ratios (OR) and 95 per cent confidence intervals (CI) for complication or death for less frequent

Table 16.5 The association of the Behavioural Marker Risk Index

with post-operative complications and death 271 Table 17.1 Definitions of types of communicative failure with

illustrative examples and notes 285

Table 18.2 Category system ‘Problem solving in a team’ 309 Table 18.3 Examples of behavioural markers for evaluating

communication in the scenarios used 310 Table 18.4 Items for evaluating medical management (Scenario 1) 311 Table 18.5 Formal characteristics of utterances in the scenarios 312 Table 18.6 Utterances related to team coordination and shared

Table 18.7 Utterances related to the team and the problem-solving

Table 19.1 Phases of a typical primary total knee replacement

Table 19.2 Descriptions and examples of minor failure types 325 Table 20.1 Selected estimations of frequency of prospective memory

based situations in medicine (mean count), error proneness of situations (mean %), and valid number

of estimations for each situation (n) 347 Table 21.1 Non-technical skills in the first simulation series 364 Table 22.1 Reference intervals for plasma and salivary cortisol 378 Table 23.1 Task sequence tracheal intubation where X = cross, SpO2

= O2 saturation, BP = blood pressure, HR = heart rate,

IV = intravenous, CO2 = carbon dioxide 393 Table 23.2 Monitors used: number of patients (%) of total n=48 at each

level of airway management task urgency Emergency

= <10 mins after admission, semi-emergency < 10–60 mins after admission and elective = > 1 hour after

Table 23.3 Task durations of intubation events Mean and standard

error of duration (in secs) of events in the intubation sequence among 11 elective and 12 emergency tracheal

Sonal Arora is a doctor of medicine and a trainee in general surgery, with a

further degree in psychology Her research interests include surgical education and training for patient safety, with a focus upon simulation and non-technical skills training She is currently completing her PhD, entitled ‘Stress, Safety and Surgical Performance.’ sonal.arora06@imperial.ac.uk

Bianca Balvert is an OR-nurse specialized in endoscopic surgery in Sint Lucas

Andreas Hospital in Amsterdam She graduated having studied the improvement

of OR patient tracking efficiency She is involved in a patient safety project in collaboration with Erasmus MC b.balvert@slaz.nl

Jonathan Beard is a consultant vascular surgeon at the Sheffield Vascular Institute,

Professor of Surgical Education at the University of Sheffield and Education Tutor

at the Royal College of Surgeons of England He has published widely on surgical skill assessment and helped to develop the Intercollegiate Surgical Curriculum Project Jonathan.D.Beard@sth.nhs.uk

Doug Bonacum is vice president – safety management for Kaiser Permanente He

leads the development, implementation and monitoring of programme-wide safety management strategies and plans with specific responsibilities for environmental, health and safety, patient safety and clinical risk management He was formerly responsible for weapons and ships safety as well as nuclear power plant operations

in the US Submarine Force doug.bonacum@kp.org

Benno Bonke is an associate professor of medical psychology at Erasmus

University Centre, Rotterdam and was trained as a clinical psychologist and psychotherapist He is the coordinator of medical education in communication skills and professional behaviour in the core curriculum in Rotterdam B.Bonke@ Erasmusmc.nl

John Brookey is assistant medical director of quality for Southern California

Permanente Medical Group, a large multi-specialty group that provides care for over three million Kaiser Permanente health-plan members He is a paediatrician

and practises at the Kaiser Permanente Pasadena Medical Office john.brookey@

kp.org

Cornelius Buerschaper is a management consultant and human factors

psychologist specializing in crisis management He is a team trainer for medical and

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managerial teams using computer simulated games for safety training and is

co-author of Crisis Management in Acute Care Settings: Human Factors and Team Psychology in a High Stakes Environment (2007) cornelius.buerschaper@

t-online.de

J Forrest Calland is an assistant professor of surgery in the University of Virginia

School of Medicine His research focuses on outcomes, safety and human factors

in high risk environments.calland@viginia.edu

Ken Catchpole is a human factors practitioner in the QRSTU, Nuffield Department

of Surgery, University of Oxford Taking a semi-ethnographic approach to understanding the complex nature of error in healthcare, he seeks to evaluate and improve the safety of surgical systems Ken.Catchpole@nds.ox.ac.uk

Jim Crossley is senior fellow in the Academic Unit of Medical Education at the

University of Sheffield and a consultant paediatrician in Chesterfield He advises and publishes widely on workplace-based assessment and psychometrics

Trevor Dale is a human factors training specialist and retired airline training

captain With Guy Hirst he is working with the NHS Institute, The Royal College

of Surgeons of England and Oxford University Nuffield Department of Surgery

Connie Dekker-van Doorn is an RN with a degree in HRD She is now working

on her PhD in collaboration with Delft University of Technology focusing on patient safety and human factors c.dekker-vandoorn@erasmusmc.nl

Peter Dieckmann is a work and organizational psychologist working with the

Danish Institute for Medical Simulation (DIMS) at the Copenhagen University Hospital in Herlev, Denmark Peter studies the use of simulations for training and research focusing on human factors studies and training of simulation instructors mail@peter-dieckmann.de

John Duncan is a consultant general and vascular surgeon at Raigmore Hospital,

Inverness He is Clinical Tutor and member of the Specialist Advisory Board in General Surgery for the Royal College of Surgeons of Edinburgh john.duncan@ haht.scot.nhs.uk

Christoph eich is consultant paediatric anaesthetist and co-director of the Centre

for Education and Simulation in Anaesthesiology, Emergency and Intensive Care Medicine at University Medical Centre Göttingen (Germany) ceich@med.uni-goettingen.de

Li Felländer-Tsai is a professor and senior consultant in orthopaedic surgery

She is the chairperson of the Department of Clinical Science, Intervention and

Technology (CLINTEC) at Karolinska Institutet and the director of the Centre for Advanced Medical Simulation at Karolinska in Stockholm, Sweden li.tsai@ki.se

Rhona Flin is professor of applied psychology, University of Aberdeen

(www.iprc.ac.uk), and she leads the Scottish Patient Safety Research Network (www.spsrn.ac.uk) Her research on safety examines leadership, culture, team skills and decision-making in healthcare and high risk industry

Kenneth T Fong is a senior managerial consultant in the Pricing Underwriting

Department for Kaiser Permanente’s Northern and Southern California regions Kenneth.t.fong@kp.org

David gaba is a medical doctor (anaesthesiology), Professor of Anaesthesia

and Associate Dean for Immersive and Simulation-based Learning at Stanford University School of Medicine He is also a Staff Anaesthesiologist at VA Palo Alto Health Care System gaba@stanford.edu

Fauzia gardezi is a clinical research project manager at SickKids Learning Institute

in Toronto and a research consultant with expertise in qualitative methodology and critical sociology fauzia.gardezi@utoronto.ca

emma giles is a specialist anaesthetist at Sir Charles Gairdner Hospital in Perth,

Western Australia She has a strong interest in teaching and assessing anaesthesia registrars and in patient safety, and is an examiner for ANZCA emma.k8@gmail com

Ronnie glavin is a consultant anaesthetist at the Victoria Infirmary in Glasgow

He also carries out various roles for NHS for Education in Scotland (NES) ronnie glavin@ggc.scot.nhsuk

Dawn goodwin is a social science lecturer in medical education She teaches

courses on various aspects of science, technology and medicine to both medical and social science students

Jodi graham is a specialist anaesthetist at Sir Charles Gairdner Hospital in

Perth, Western Australia She is a supervisor of anaesthesia training, and her main interests are in education and simulation jgraham@meddent.uwa.edu.au

Suzanne graham is director of patient safety for Kaiser Permanente Suzanne has

served in multiple roles within Kaiser Permanente at the medical centre, regional and national levels She has a BSN in nursing as well as Masters degrees in school health and developmental disabilities from San Francisco State University Her doctoral degree is from a combined programme at Baylor, University of Texas, and University of Houston Suzanne.Graham@kp.org

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gudela grote is professor of work and organizational psychology at the ETH

Zurich, Switzerland She is Associate Editor of the journal Safety Science and has

consulted on safety management for companies like Swiss Re, Deutsche Bahn AG and the Swiss Nuclear Inspectorate ggrote@ethz.ch

Stephanie guerlain is associate professor of systems and information engineering

at the University of Virginia, USA Her research focuses on human–computer interaction, particularly information visualization, training system design and the design of decision support systems guerlain@virginia.edu

Leif hedman is a licensed psychologist and associate professor at the Department

of Psychology, Umeå University, expert in medical human factors He is also

an affiliated researcher at the Department of Clinical Science, Intervention and Technology (CLINTEC) and the Centre for Advanced Medical Simulation at Karolinska in Stockholm, Sweden Leif.Hedman@psy.umu.se

guy hirst founded Atrainability Limited with Trevor Dale in 2002 He recently

retired as a training standards captain from British Airways Since 2001 he has been involved in several research projects training multidisciplinary teams in various healthcare environments guy.hirst@atrainability.co.uk

graham hocking is a specialist anaesthetist at Sir Charles Gairdner Hospital,

Perth, Western Australia His main interests are research, education and regional anaesthesia

Gesine Hofinger is a human factors psychologist specializing in patient safety

and management of critical incidents She is a member of the advisory board of

the German Coalition for Patient Safety and co-author of Crisis Management

in Acute Care Settings: Human Factors and Team Psychology in a High Stakes Environment (2007) gesine.hofinger@t-online.de

Steve howard is an associate professor of anaesthesia at Stanford University

School of Medicine and a staff anaesthesiologist at the VA Palo Alto Health Care System showard@stanford.edu

Robbert huijsman is part-time professor of management of integrate care at the

department of Health Policy and Management of Erasmus University Rotterdam

He combines his scientific work with a partnership in a healthcare consultancy firm (Zorg Consult Nederland)

Rosamond Jacklin is a specialist registrar in general surgery After graduating

from medical school in 2000, Ros undertook basic surgical training and the MRCS, then completed a PhD at Imperial College (2004–2008) entitled ‘Judgment and Decision Making in Surgery’ r.jacklin03@imperial.ac.uk

Shelly Jeffcott is a senior research fellow at the NHMRC Centre of Research

Excellence in Patient Safety and has a background in psychology and the

examination of risk and safety in high hazard industries Shelly.Jeffcott@med.

monash.edu.au

geert Kazemier is hepatobiliary and transplant surgeon at Erasmus Medical

Centre He is also responsible for the Operating Room Department at that institution G.kazemier@erasmusmc.nl

Jan Klein is professor of anaesthesiology at the Erasmus University Medical

Centre He developed a special interest in peri-operative patient safety and is the President of the Netherlands Society of Anaesthesiology j.klein@erasmusmc.nl

Michaela Kolbe is work and organizational psychologist and research assistant

at the Organization, Work and Technology Group at ETH Zurich, Switzerland mkolbe@ethz.ch

Barbara Künzle is work and organizational psychologist and research assistant

at the Organization, Work and Technology Group at ETH Zurich, Switzerland bkuenzle@ethz.ch

Johan Lange is professor of surgery in the department of surgery of the Erasmus

University Medical Centre in Rotterdam, the Netherlands He is Associate Dean of the Faculty of Medicine of the Erasmus University and President of the Committee

of Patient Safety of the Dutch Society of Surgery J.lange@erasmusmc.nl

Robert Lasky is a professor of paediatrics and the director of the Design and

Analysis Support Services for the Centre of Clinical Research and Evidence Based Medicine at the University of Texas Medical School at Houston Robert.E.Lasky@ uth.tmc.edu

Lorelei Lingard is senior scientist in the SickKids Research Institute and the Wilson

Centre for Research in Education, University Health Network and University of Toronto She is the inaugural holder of the BMO Financial Group Professorship in Health Professions Education Research lorelei.lingard@utoronto.ca

Colin Mackenzie is professor of anaesthesiology and associate professor of

physiology at the University of Maryland School of Medicine His research interests include human factors in emergencies, and trauma resuscitation He has been continuously funded by Federal grants for the past 18 years cmack003@ umaryland.edu

Marlene Dyrløv Madsen works at the Danish Institute for Medical Simulation

(DIMS) as a researcher in patient safety and safety culture She has a PhD in

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patient safety and ethics of patient safety, and holds a Masters in philosophy and communication mdyrloev@ruc.dk

Tanja Manser is a senior lecturer at the Centre for Organizational and

Occupational Sciences, ETH Zurich, where she is heading a research group on human performance and safety in complex systems tmanser@ethz.ch

nikki Maran is a consultant anaesthetist in The Royal Infirmary of Edinburgh and

Director of the Scottish Clinical Simulation Centre in Stirling Her interests are in anaesthesia for emergency surgery, education for patient safety and non-technical skills training and assessment

Joy Marriott is a specialty registrar in obstetrics and gynaecology, currently

working towards an MD in surgical education and a Masters of Education at the University of Sheffield Her research interests include workplace assessment and competency-based selection Joy.Marriott@sth.nhs.uk

Karen R Mazzocco is a nurse-attorney with 20 years of experience as a surgical

director, primarily at the University of Cincinnati where she achieved her BSN and Juris Doctor She practised law in hospitals in New York and New Mexico Since 2001, she worked in research in surgical and perinatal patient safety during affiliations at Kaiser Permanente in California Currently, she is affiliated with Sharp Healthcare in San Diego, CA, in the evolving field of patient service and satisfaction karen.mazzocco@sharp.com

Peter McCulloch is clinical reader at the Nuffield Department of Surgery in

Oxford He founded the Quality, Reliability, Safety and Teamwork Unit (QRSTU)

in 2005, which focuses on evaluating interventions to improve the functionality of modern healthcare systems peter.mcculloch@nds.ox.ac.uk

Lisbet Meurling is specialist in anaesthesia and intensive care medicine and

participant of the Scandinavian Society of Anaesthesiology training programme in intensive care medicine She is a PhD student at CLINTEC, Karolinska Institutet lisbet.meurling@karolinska.se

Ami Mishra is a surgical registrar on the Oxford rotation, whose MD project

examined the value of an aviation-style team training approach to improving safety in the operating theatre He hopes to maintain his research throughout and beyond his training ami.mishra@nds.ox.ac.uk

Lucy Mitchell is a research assistant in the Industrial Psychology Research

Centre, University of Aberdeen, investigating non-technical skills of nurses/scrub practitioners She previously studied police firearms officers’ decision-making skills and was formerly a police officer l.mitchell@abdn.ac.uk

Maggie Mort is reader in the sociology of science, technology and medicine

and co-director of the Centre for Science Studies at Lancaster University, UK

An ethnographer, her research interests include new medical technologies, telehealthcare and disaster recovery m.mort@lancaster.ac.uk

Michael Müller is consultant anaesthetist at the Hospital of Technical University

and Director of Interdisciplinary Medical Simulation Centre, Dresden, Germany mp-mueller@web.de

David Musson is an assistant professor and Director of the Centre for

Simulation-Based Learning at McMaster University in Hamilton, Canada He received his

MD from the University of Western Ontario, and PhD in psychology from the University of Texas at Austin musson@mcmaster.ca

Andrea nickut is a research student at the Centre for Education and Simulation in

Anaesthesiology, Emergency and Intensive Care Medicine at University Medical Centre Göttingen (Germany) andreanickut@web.de

Simon Paterson-Brown is a consultant general and upper gastro-intestinal

surgeon at the Royal Infirmary Edinburgh and an honorary senior lecturer at the University of Edinburgh Simon.Paterson-Brown@luht.scot.nhs.uk

Rona Patey is a consultant anaesthetist at Aberdeen Royal Infirmary She is also

the Director of the Clinical Skills Centre at Foresterhill and Deputy Head of the University of Aberdeen Division of Medical and Dental Education r.patey@abdn ac.uk

Diana Petitti is a physician (preventive medicine) and medical doctor (MD) She

is Professor in the Department of Biomedical Informatics in the Fulton School of Engineering at Arizona State University diana.petitti@asu.edu

David Pitts is a psychologist with a background in management development

He is Project Coordinator of the UK orthopaedic curriculum (OCAP), Associate Director of Leadership and Educational Development at the Royal College

of Surgeons of Edinburgh and Education Advisor to the British Orthopaedic Association d.pitts@rcsed.ac.uk

Catherine Pope is reader in the school of health sciences, University of

Southampton Her research includes evaluations of organizational change and studies of surgical practice She is currently researching the use of computer decision support in urgent and emergency care, and ambulance handovers.cjp@ soton.ac.uk