Safer Surgery part 37 potx

Failures to control distraction and safety are therefore symptomatic of the impact of culture on surgical quality Baird et al.. By taking a prospective approach to the observation of sys

The high incidence of distracters suggests that both the opportunity for and tolerance of external interference was high Instances of reduced safety consciousness were also high, which was surprising considering the well-recognized and highly undesirable effect that nosocomial infection can have on the outcome of joint replacement surgery (Gao et al 2000) Though equivocal evidence has been offered for the effectiveness of mask discipline for control of nosocomial infection (McLure et al 1998, Mitchell and Hunt 1991), protocols should be applied consistently and particular attention should be paid to prosthetic implantation (Woodhead et al 2002) Controlling the use of the telephone in theatre and reinforcing safety procedures are simple and direct solutions that could and should be applied On a number of occasions senior team members attempted

to maintain standards with little success, and in one instance an individual not involved with the operation entered the theatre during the procedure, initially without a mask, made a loud and argumentative phone call without the permission

of anyone in the operating team, then left theatre, violating mask protocol on the way out Failures to control distraction and safety are therefore symptomatic of the impact of culture on surgical quality (Baird et al 2005), and rather than blaming individuals, the aetiology of this problem should be considered at all levels, from hospital management, through professional societies and associations, to national policy

Unlike other types of surgery, which may be reliant on the scalpel-and-suture skills of the surgeon, TKR and TKR revision operations are reliant on the appropriate use of procedure-specific instruments Achieving the correct equipment configuration is a key technical skill for this type of surgery Though the instruments are usually reliable, the wide range of equipment required in a short space of time placed pressure on the operating team For example, the ten-minute period from the first incision to completion of the femoral cuts for one make of implant requires the use of five specialist instruments (intra-medullary rod, femoral locating device, distal femoral cutting block, femoral sizing guide and anterior/posterior chamfer cutting block), as well as a range of other incidental equipment such as drills, saws, retractors, pins, hammers, scalpels, swabs, diathermy and suction A surgeon cannot perform the operation without the scrub nurse to provide the appropriate instruments, and a scrub nurse cannot support the surgeon effectively if they are overloaded, distracted or unable to keep up with and anticipate the surgical tasks Given the skill required for both roles, the mutual trust required and the authority gradient between them, this relationship is brittle

It was encouraging that in the present study the interaction between surgeons and scrub nurses was mutually supportive almost without exception, and remained solution-focused when things did not go according to plan

In the TKR revision operations, which were always more demanding, the active participation of the prosthetic manufacturer sales representative helped the theatre and surgical staff to appropriately manipulate the even more complex and less familiar instrumentation, as well as providing an additional resource for aiding coordination and error capture However, while this can have exceptional

safety benefits, it can also have negative effects on the rest of the team, and often caused distraction, accounting for the high level of organizational/cultural threats in high risk operations This also suggests a deficiency in the design of the instruments, which seemed too complex for surgical teams to use without a considerable amount of additional, manufacturer-specific training It also raises ethical concerns Overall, though patient-related difficulties were frequent, the difficulty of the operation was more dependent upon the design and management

of the equipment, the coordination of the team, and the more frequent but generally less serious cultural threats

This study provides further evidence of the value of expert observers in identifying threats to patient safety, and suggests several structured interventions

to improve surgical quality Since equipment management failures were closely associated with the effectiveness of the team, attention to non-technical skills could be immediately beneficial (Fletcher et al 2002, Healy et al 2004) Non-technical skills which are neither formally taught nor included in competency assessments can also be useful in avoiding or capturing problems before they can accumulate (Carthey et al 2003, de Leval et al 2000, Helmreich 2000) Indeed the provision of pre-operative briefings, post-operative debriefings and non-technical skills development may provide a highly effective and long-term practitioner-driven safety and learning mechanism through which a broad range of inter-operative problems might be addressed Further assessment of team-based non-technical skills was made during these operations, and has been independently reported (Catchpole et al 2008) Attempts to improve the design and usability of equipment, and to reduce the number and range of specialist instruments (Nizard

2002, Nizard et al 2004), should also be encouraged, provided appropriate human factors (Malhotra et al 2005) and safety considerations (Lieberman and Wenger 2004) are present early in the design process The observations of the computer-assisted system suggest that while equipment management issues are being partially addressed in new technologies, this can re-locate failures, making currently reliable and easy-to-configure instrumentation less reliable and more difficult to use in the future Indeed, it is the opinion of the author after observing nearly 200 operations

in at least six treatment centres that the systems for procuring, maintaining, and training for operating theatre equipment are either poorly managed or barely extant, compromising the safety of existing technologies, even before the increased risks associated with new technology are considered

Conclusions

The most frequent failures may not always demonstrate the greatest threat to operative success or system function, but they can provide the environment in which major failures and adverse events are more likely Examination of the fundamental properties of the system that these minor failure types display allows the identification of a small number of error reduction strategies that address the

problem at the source This is more advantageous than providing defences to a large number of unique deficiencies, since safety systems themselves can become brittle, ineffective and add to the problems in the system if too many defences are implemented (Cook and Woods 1994) The failure source model provides a diagnosis of the likely source of threats and errors in this operating theatre and

in this type of surgery An estimate based on current failure rates (Feinglass et

al 2004, Vincent et al 2001) and projected surgical volume (Dixon et al 2004) suggests that in 2010 between 2000 and 9000 patients in the UK will experience some form of adverse event following a TKR By taking a prospective approach

to the observation of system failures and human error in orthopaedic surgery, this chapter has identified problems with the organization and culture of safety, problems associated with the design and organization of the equipment in theatre which become amplified in more difficult operations, and the potential for improved non-technical performance in the operating team Attention to these deficiencies in operating theatres would result in improvements in patient safety, surgical quality and system efficiency

Acknowledgements

This project was funded by the Department of Health Patient Safety Research Programme Thanks to Mr Tony Giddings and Prof Marc de Leval for their comments on earlier versions of this text, to Dr Paul Godden for his assistance in the data collection, and to Trevor Dale, Guy Hirst, Peter McCulloch and Michael Wilkinson for their assistance in various aspects of these studies The preparation

of this chapter was kindly supported through a Leverhulme Trust Early Career Fellowship

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Remembering To Do Things Later and Resuming Interrupted Tasks: Prospective

Memory and Patient Safety

Peter Dieckmann, Marlene Dyrløv Madsen, Silke Reddersen,

Marcus Rall and Theo Wehner

introduction

In this chapter we take a closer look at tasks requiring some form of prospective memory (PM) which allows people to remember to do something in the future or

to resume interrupted tasks

examples of Prospective Memory from the Operating Room

Example 1 – Treatment in Time

A patient is scheduled for surgery, requiring peri-operative antibiotics to prevent infection It is absolutely critical that the antibiotics are applied some time before the surgeon cuts the skin It is believed that allergic reactions are more frequent if antibiotics are given to conscious patients So, when the patient arrives with the antibiotic taped to his chart, the anaesthesia team first induces anaesthesia and then has to remember to give the antibiotic, whilst preoccupied with many other tasks before the surgery starts

Example 2 – Recurrent Measurements

A patient with insulin-dependent diabetes has to undergo major surgery, lasting several hours After taking an initial blood glucose level measurement before anaesthesia, the anaesthetist must then repeatedly measure the blood glucose

of the anaesthetized patient Severe brain damage may result in the case of prolonged low blood glucose There will be several occasions during the surgical procedure where the ‘countdown timer’ will beep, but the anaesthetist will not be able to respond, because of other ongoing critical tasks (e.g., blood transfusion, hemodynamic management) It will be a repeated challenge not to forget the

checking of the blood glucose, which might be postponed for a while but must not

be forgotten for too long

Example 3 – Dynamic Change of Plans

A patient with a history of several laparotomies due to a renal disability in his

childhood is admitted to the clinic with an acute abdomen In the CT scan nothing

specific can be found, so the patient is scheduled for an explorative laparoscopy and it is decided to perform an appendectomy, as ‘no one would like to have to operate on this patient’s abdomen again’ The operation is rather difficult due to multiple adhesions There is a danger of abdominal injury, so the surgeon really has to concentrate on his task Sometime during the operation he has to remember

to also perform the appendectomy

We will concentrate our discussion mainly on PM and its failures in the operating room (OR) We will explain the concept of prospective memory in some detail and explain how it is relevant for medical care and patient safety

We will use the PM theoretical framework (Brandimonte et al 1996) to analyse the examples above and use data from a questionnaire and a simulator study to illustrate the relevance of PM for acute medical care Finally, we will discuss implications for PM-related research and medical practice and patient safety The longer-term goal of an improved understanding of this error form is to identify how best to deal with this challenge: removing error prone situations systematically, implementing protective measures and training people to optimize performance

in PM situations So far, we have only begun to investigate PM and its failures in acute care settings and it is too early to give sound advice on effective protection and countermeasures

Relevance in the Operating Room (OR) and Other Acute Care Settings

The examples above emphasize the relevance and face value of prospective memory (PM) for medical practice With rationalization, cost and time pressure, healthcare professionals are responsible for more than one and, sometimes several patients Interruptions and delays are frequent in the different healthcare settings (Manser et al 2003, Healey et al 2006, Chisholm et al 2000, Dieckmann et al

2006, Dyrløv Madsen and Schou 2008) Interruptions in medical care have been found to be related to a preference for direct (synchronous) communication modes

in medicine, for example face-to-face communications Whilst using synchronous channels might help to decrease memory burden (e.g., by delegating tasks), it also increases the potential for interruptions when compared to asynchronous communication channels, like email or voice mails (Parker and Coiera 2000) Delays and interruptions in the OR stem from task inherent difficulties (complications) and, the social, technical and organizational environment (Healey

et al 2006) For example, tasks are begun and finished, usually in a desynchronized

fashion, by the separate crews (Gaba et al 2001) involved in the treatment in the

OR (e.g., anaesthesia crew, surgical crew, cleaning crew, etc.) While an individual starts a certain task (e.g., the anaesthetist places a nerve block before surgery to improve post-surgery care and comfort), the surgical crew might simply wait

or fill the waiting time by beginning other tasks or taking a break – potentially outside the OR The coordination of the interdependent tasks is at times imprecise (e.g., only rough or understated estimations of how long a task will take), leading

to prolonged delays While the above anaesthetist might underestimate the task duration (‘I will be finished in five minutes’ – where the task might actually take

15 minutes), the surgical crew might underestimate the duration of the task they

do in between (‘Anaesthesia will never finish in five minutes, so let’s start our task – that might take 20 minutes’) After finishing placing the nerve block and waiting for the surgical crew to finish, the anaesthetic crew might then begin their next task

to fill the waiting time, and so on To exit this vicious circle, the interdisciplinary team would have to be very well coordinated, accept unproductive waiting time for some team members, or have to interrupt or speed up a task

So far there are few data that directly link prospective memory and its failures to the quality and safety of care, but there is some implicit evidence, also from other disciplines, especially aviation, where PM failures were found

to be important (Dismukes and Nowinski 2006) Some evidence within medicine stems from incident reporting systems The MedMARx incident reporting system (<www.usp.org/medmarx>) collects information on medication errors In a report,

6224 cases were analysed for underlying causes and contributing factors (US Pharmacopeia 2000) Interruptions of actions were found as contributing factors in

14 percent of the cases with negative consequences Also, safety culture (Dyrløv Madsen et al 2007, Itoh et al 2007) seems to have an impact on interruptions

In an investigation with 2000 participants, a Danish safety culture questionnaire study showed that 69 percent of the participating healthcare professionals agree or highly agree that interruptions are reasons or contributing factors for adverse events (Dyrløv Madsen and Schou 2008) Finally, there is much anecdotal evidence from healthcare professionals who often respond enthusiastically to the concept of PM, claiming that it describes very common experiences of daily practice

interruptions as Situations with high PM Burdens

Many different situations place a high burden on PM: interruptions, distractions, parallel tasks, delays, etc In the following section we focus on interruptions to narrow the scope of the discussion, allowing for more thorough analysis

Interruptions and distractions are known to have a negative impact on performance, as they influence and minimize the professionals’ ability to stay focused on a specific task (intention) (Beyea 2007) By analysing PM errors in interruption situations, it will also be possible to take a work analytical stance Investigating PM errors in interruptions will help in understanding the personal

redefinition of tasks What do professionals see as an interruption (from the outside, e.g., by colleagues, alarms, telephone), a distraction (from the inside, e.g., sudden thoughts or ideas, difficulties in concentrating, inner resistances) and a task-inherent challenge (e.g., difficulties during intubation or finding the correct differential diagnosis)? This perspective is especially important in the multiple-crew, interdependent task context of most acute medical care settings What does one crew accept as a legitimate task of the other crew? What do they see as a necessary interruption? What is accepted and what is not? These factors might influence the crew and team climate, the willingness to cooperate and thus, also patient safety

Analysing PM errors in the interruption context will allow for supplementing the cognitive perspective with social aspects Most professionals both expect and accept interruptions as part of their normal work day (Beyea 2007, Parker and Coiera 2000) From the cognitive perspective, those interruptions might be helpful

to decrease one’s own memory load interrupting a colleague and delegating the task frees one’s own cognitive resources however, this interruption may increase that colleague’s cognitive load From the social perspective, interruptions might

be related to reciprocal acceptance: accepting being disrupted and asked for help might, in turn, legitimize oneself interrupting others later Interruptions are likely

to be related to hierarchy as well: they could be seen as a status symbol (‘I am important and needed – people interrupt me and I can help solve their problems’) but also as an integral part of a certain position (by definition and job description,

a consultant is a centre in a complex network of information flow with many

‘inputs’ and ‘outputs’ and thus interruptions) (Groopman 2007, Jauhar 2007) A recent observational study of nurses and doctors in an oncological ambulatory unit in a Danish hospital revealed many disturbances and interruptions in the daily workflow (Dyrløv Madsen and Schou 2008) Their study documented a large number of interruptions, especially for nurses, which often resulted in staff forgetting to finish tasks Nevertheless, during post-observation interviews about the observed events, the professionals, on the whole, found them appropriate, legitimate and were able to justify their frequency The interviewees claimed the interruptions were appropriate for the task at hand and/or to improve teamwork

On further reflection and discussion with the interviewer the professionals, however, recognized that many of the interruptions were a problem for patient safety and that they probably could be minimized or avoided if everyone was dedicated to do so Therefore, how interruptions are perceived seems to be inherent to the professional culture

Finally, interruptions are relevant for PM research as it might be easier to identify the underlying intention, as compared to other situations like delays

in having the opportunity to execute a certain intention We will discuss this aspect in more detail below In summary, by studying interruptions in relation

to PM in acute medical care, we hope to advance the knowledge about this error type

Definition of Prospective Memory and its Failures

Prospective memory is defined as a psychological processes which enable humans

to execute previously formed intentions during an appropriate but delayed ‘window

of opportunity’ (Harris and Wilkins 1982) without being explicitly reminded to do

so (Dieckmann et al 2006; for an overview see Brandimonte et al 1996) Not resuming the interrupted task, resuming the interrupted task at the wrong spot (missing a step or wrongly performing a step more than once) or not executing

an intended task might be related to errors of PM However, in order to make this

‘error diagnosis’, differential diagnoses need to be considered Not resuming or executing a task might be related to a conscious decision (which might in itself be right or wrong), it might be because the window of opportunity was not recognized,

or that other cognitive and emotional processes prevented the execution (e.g., unconscious resistances) Weimer (1925) suggested that one needs to distinguish between error forms (here: missing the execution of an intention, failing to resume

a task or resuming it at the wrong spot) from the underlying error types, i.e., the underlying psychological processes (e.g., forgetting, denying, deciding against it) What might look like the same error from the ‘outside’ (error form: an intended task is not executed), might be very different from the ‘inside’ Focusing on PM

in interruptions as a situation type/error form helps in narrowing the search space for underlying error types

In general, one can distinguish between different classes of PM tasks, depending

on how the window of opportunity is to be described: activity-based PM tasks (i.e., do X after you are finished with M, see Example 3, ‘Dynamic change of plans’, above), event-based PM tasks (i.e., do X when Y occurs, see Example 1,

‘Treatment in time’) and time-based PM tasks (i.e., do X at time Z, see Example

2, ‘Recurrent measurements’)

Within the PM framework, five phases are distinguished that belong to a full

PM cycle (Ellis 1996):

In the beginning, the intention is formed and encoded, containing three components: that, what and when The that component can be seen as

energizing the inner system, preparing the person to act at all (Goschke and

Kuhl 1993, Lewin 1926) The what component specifies what needs to be done in more detail The when component helps in anticipating the window

of opportunity in a temporal and conditional sense

During the retention phase the intention is kept in memory, more or less

consciously, while the duration of the interval does not seem to have a large impact on the retention of the intention and its execution (Kvavilashvili and Ellis 1996) Short interruptions might be enough to hinder the execution of intentions

The window of opportunity begins and the intention could be executed It is

a question of whether the person intending to act recognizes the beginning

of the window of opportunity and is also able to retrieve the intention For

1

2

3