Safer Surgery part 35 pot

Quality of Communication in Critical SituationsQuality of Communication as Evaluated by the Behavioural Markers How well do the participants fulfil the expectations concerning good commu

Quality of Communication in Critical Situations

Quality of Communication as Evaluated by the Behavioural Markers

How well do the participants fulfil the expectations concerning good communication that we formulated as behavioural markers? The number of behavioural markers confirmed 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

of the relationship

Reflection/

emotional utterances

Process Total

Table 18.7 utterances related to the team and the problem-solving process

The Influence 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; confirming 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 (confirming understanding; explanation of one’s own activity) did not significantly 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 findings 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

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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

Behavioural markers

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 confirm 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 finding 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 The observing tools presented here need to be developed further Currently we are involved in a small study on team management

in the emergency department The aim is to find out how teams in emergency rooms organize and how they communicate in order to solve complex problems We will test our observation tool for team problem solving in the emergency room setting

to investigate whether observation in a multi-player context can be achieved with sufficient accuracy

The communication data permit the deduction of the following training

contents: explicit formation of shared mental models (especially relating to the

future development of the situation) and organisation of action (stages of the problem-solving process)

References

Bauer, M and Gaskell, G (eds) (2000) Qualitative Researching with Text, Image and Sound: A Practical Handbook for Social Research London: Sage.

Cannon-Bowers, J.A and Salas, E (2001) Reflections on shared cognition

Journal of Organizational Behavior 22, 195–202.

Cannon-Bowers, J.A., Tannenbaum, S.I., Salas, E and Volpe, C.E (1995) Defining team competencies and establishing team training requirements In R Guzzo

and E Salas (eds), Team Effectiveness and Decision Making in Organizations

(pp 330–80) San Francisco: Jossey-Bass

Carthey, J., de Levala, M.R., Wright, D.J., Farewell, V.T and Reason, J.T (2003)

Behavioural markers of surgical excellence Safety Science 41(5), 409–25.

Coiera, E and Tombs, V (1998) Communication behaviors in a hospital setting:

An observational study British Medical Journal 316, 673–6.

Davies, J (2001) Medical applications of crew resource management In E

Salas, C Bowers and E Edens (eds), Improving Teamwork in Oranizations Application of Resource Management Training (pp 265–81) Mahwah:

Lawrence Erlbaum

Dietrich, R and von Meltzer, T (eds) (2003) Communication in high risk

environments Linguistische Berichte, special issue 12 Hamburg: Buske Dörner, D (1996) The Logic of Failure Recognizing and Avoiding Error in Complex Situations New York: Metropolitan Books.

Dörner, D., Reither, F and Stäudel, T (1983) Lohhausen Über den Umgang mit Komplexität und Unbestmmtheit [On Dealing with Complexity and Uncertainty] Bern: Huber.

Entin, E and Serfaty, D (1999) Adaptive team coordination Human Factors

41(2), 312–25

Fletcher, G., Flin, R., McGeorge, P., Glavin, R., Maran, N and Patey, R (2003) Anaesthetists’ Non-Technical Skills (ANTS): Evaluation of a behavioural

marker system British Journal of Anaesthesia 90(5), 580–8.

Fletcher, G., Flin, R., McGeorge, P., Glavin, R., Maran, N and Patey, R (2004) Rating non-technical skills: Developing a behavioural marker system for use

in anaesthesia Cognition, Technology and Work 6, 165–71.

Frensch, P.A and Funke, J (eds) (1995) Complex Problem Solving: The European Perspective Hillsdale, NJ: Lawrence Erlbaum Associate.

Gaba, D.M (1992) Dynamic decision-making in anesthesiology: Cognitive models

and training approaches In D Evans and V Patel (eds) Advanced Models of Cognition for Medical Training and Practice (pp 122–47) Berlin: Springer.

Gaba, D.M., Howard, S.K., Flanagan, B., Smith, B.E., Fish, K.J and Botney, R (1998) Assessment of clinical performance during simulated crises using both

technical and behavioral ratings Anesthesiology 89(1), 8–18.

Glavin, R.J and Maran, N.J (2003) Integrating human factors into the medical

curriculum Medical Education 37 (November, Suppl 1), 59–64.

Grommes, P (2000) Contributing to coherence: An empirical study on OR-team-communication In M Minnick-Fox, A Williams and E Kaiser (eds),

Proceedings of the 24th Penn Linguistics Colloquium, U Penn Working Papers

in Linguistics, 7.1 Philadelphia, PA: University of Pennsylvania

Häusler, R., Klampfer, B., Amacher, A and Naef, W (2004) Behavioral markers

in analyzing team performance of cockpit crews In R Dietrich and T.M

Childress (eds), Group Interaction in High Risk Environments Aldershot:

Ashgate

Howard, S.K., Gaba, D.M., Fish, K.J., Yang, G and Sarnquist, F.H (1992) Anesthesia crisis resource management training: Teaching anesthesiologists to

handle critical incidents Aviation, Space and Environmental Medicine 63(9),

763–70

Jensen, R (1995) Pilot Judgement and Crew Resource Management Aldershot:

Ashgate

Joint Aviation Authorities (2006) JAR-OPS 1.965 (Appendix) JAR-FCL-1

Available at: <http://www.jaa.nl/publications/jars/607069.pdf> [last accessed March 2009]

Klimoski, R and Mohammed, S (1994) Team mental model: Construct or

metaphor Journal of Management 20(2), 403–37.

Kohn, L., Corrigan, J and Donaldson, M (eds) (1999) To err is human: Building a

safer health system Committee on Quality of Health Care in America, Institute

of Medicine (IOM) Washington DC: National Academy Press.

Merrit, A.C and Helmreich, R.L (1997) CRM: I hate it, what is it? (Error, stress,

culture) Proceedings of the Orient Airlines Association Air Safety Seminar Jakarta, Indonesia, April 23, 1996 (pp 123–34) Manila: Orient Airlines

Association Available at: <http://homepage.psy.utexas.edu/homepage/group/ HelmreichLAB/> [last accessed March 2009]

Mishra, A., Catpole, K., Dale, T and McCulloch, P (2008) The influence of non-technical performance on non-technical outcome in laparoscopic cholecystectomy

Surgical Endoscopy 22(1), 68–73.

Morey, J.C., Simon, R., Jay, G.D., Wears, R.L., Salisbury, M., Dukes, K.A., et

al (2002) Error reduction and performance improvement in the emergency department through formal teamwork training: Evaluation results of the

MedTeams project Health Services Research 37(6), 1553–81.

Orasanu, J (1990) Shared Mental Models and Crew Performance Princeton, NJ:

Princeton University, Cognitive Sciences Laboratory

Pettinari, C.J (1988) Task, Talk, and Text in the Operating Room: A Study in Medical Discourse Norwood, NJ: Ablex Publishing.

Reader, T., Flin, R., Lauche, K and Cuthbertson, B.H (2006) Non-technical skills

in the intensive care unit British Journal of Anaesthesia 96(5), 551–99.

Risser, D.T., Rice, M.M., Salisbury, M.L., Simon, R., Jay, G.D and Berns, S.D (1999) The potential for improved teamwork to reduce medical errors in

the emergency department The MedTeams Research Consortium Annals of Emergency Medicine 34(3), 373–83.

Salas, E., Burke, C.S., Bowers, C.A and Wilson, K.A (2001) Team training in the

skies: Does crew resource management (CRM) training work? Human Factors

43(4), 641–74

Salas, E., Wilson, K.A., Burke, C.S and Wightman, D.C (2006) Does crew resource management training work? An update, an extension, and some

critical needs Human Factors 48(2), 392–412.

Schöbel, M., and Kleindienst, C (2001) The psychology of team interaction Acta Neurochirurgica suppl 78, 33–8.

Sexton, J.B., and Helmreich, R.L (2000) Analyzing cockpit communications:

The links between language, performance, error, and workload Human Performance in Extreme Environments 5(1), 63–8.

Silberstein, D (2001) Final Report of the Subproject ‘Initiating Team Resources under High Cognitive Workload’ Berlin: Technische Universität.

St Pierre, M., Hofinger, G., Buerschaper, C., Grapengeter, M., Harms, H., Breuer, G., et al (2004) Simulator-based modular human factor training in anesthesiology Concept and results of the module ‘Communication and Team

Cooperation’ Anaesthesist 53(2), 144–52.

St Pierre, M., Hofinger, G and Buerschaper, C (2007) Crisis Management in Acute Care Settings: Human Factors and Team Psychology in a High Stakes Environment New York: Springer.

Stempfle, J.J and Badke-Schaub, P (2002) Kommunikation und Problemlösen

in Gruppen: eine Prozessanalyse [Communication and problem solving in

groups: A process analysis] Gruppendynamik und Organisationsberatung [Group Dynamics and Organizational Consultancy] 33(1), 57–81.

Stempfle, J.J and Badke-Schaub, P (2003) Eine integrative Theorie des Problemlösens in Gruppen I: Problemlöseprozess und Problemlöseerfolg [An integrative theory of problem solving in groups I: Problem solving process

and problem solving success] Gruppendynamik und Organisationsberatung [Group Dynamics and Organizational Consultancy] 35(4), 335–58.

Stout, R., Cannon-Bowers, J.A., Salas, E and Milanovich, D (1999) Planning, shared mental models, and coordinated performance: An empirical link is

established Human Factors 41(61–71).

Thomas, E.J., Sexton, J.B and Helmreich, R.L (2004) Translating teamwork behaviors from aviation to healthcare: Development of behavioural markers

for neonatal resuscitation Quality of Safety in Health Care 13 (suppl 1), 57–

64

Transportation, U.S.D (1998) Crew Resource Management Training, AC No: 120-51C Advisory Circular (AC) Available at: <http://www.crm-devel.org/

resources/ac/ac120_51c.htm> [last accessed November 2008]

Undre, S., Koutantji, M., Sevdalis, N., Gautama, S., Selvapatt, N., Williams, S., Sains, P., McCulloch, P., Darzi, A and Vincent, C (2007) Multidisciplinary

crisis simulations: The way forward for training surgical teams World Journal

of Surgery 31(9), 1843–53.

Wiener, E.L., Kanki, B and Helmreich, B (eds) (1993) Cockpit Resource Management San Diego: Academic Press.

Yule, S., Flin, R., Paterson-Brown, S., Maran, N and Rowley, D (2006)

Development of a rating system for surgeons’ non-technical skills Medical Education 40(11), 1098–104.

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 deficiencies 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 deficient 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 identification of weak points in the system has three important advantages; it is resistant to hindsight bias, which often afflicts 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 efficiency 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

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 profile 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 first 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:

confirm that the escalation from small problems to serious risk was influenced 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 first 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

•

•

•

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 field 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 field, 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 artificial 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 first incision is made, and carried to the knee capsule.

5 The knee is dislocated, and an intra-medullary rod inserted to fix 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

configuration of the tibial cutting block.

8 Trial tibial and femoral prostheses are used to test the fit and confirm 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 firmly seated The leg is again checked for fit.

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