Safer Surgery part 3 doc

helen.purdie@sth.nhs.uk Marcus Rall is an anaesthetist and the director of the Centre for Patient Safety and Simulation TüPASS at the University of Tuebingen, Germany.. He is Director o

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helen Purdie is a senior research sister at the Clinical Research Facility in

Sheffield She has also gained surgical experience as a surgical care practitioner (SCP) within the specialties of cardiac and vascular helen.purdie@sth.nhs.uk

Marcus Rall is an anaesthetist and the director of the Centre for Patient Safety and

Simulation (TüPASS) at the University of Tuebingen, Germany Marcus is leading the two incident reporting systems and PaSOS Marcus.rall@med.uni-tuebingen de

Silke Reddersen is anaesthetist at Tuebingen University Hospital, Germany She

works for the Tuebingen Centre for Patient Safety and Simulation with an emphasis

on in-situ trainings, instructor training and the German Incident Reporting systems PaSIS and PaSOS silke.reddersen@freenet.de

glenn Regehr is Richard and Elizabeth Currie Chair in Health Professions

Education Research, Professor and Senior Scientist at the Wilson Centre for Research in Education, University Health Network and University of Toronto g.regehr@utoronto.ca

David Rowley is an orthopaedic surgeon He is Director of Education at the Royal

College of Surgeons of Edinburgh as well as Visiting Professor of Surgery at Edinburgh University, and Emeritus Professor at Dundee University d.i.rowley@ dundee.ac.uk

nick Sevdalis is an experimental psychologist Initially a post-doctoral researcher

in the Imperial Department of Surgery (2004–2006), Nick was appointed Lecturer

in Patient Safety (2006 to the present) – with two years spent jointly in Imperial and the National Patient Safety Agency (2006–2008) Nick investigates non-technical skills/teamwork in surgery n.sevdalis@imperial.ac.uk

J Bryan Sexton is a psychologist by training and is the Director of Safety Culture

Research and Practice at the Johns Hopkins Quality and Safety Research Group

He has collected culture data in over 2000 hospitals, in 15 countries

Andrew Smith is a consultant anaesthetist at the Royal Lancaster Infirmary and

Honorary Professor of Clinical Anaesthesia at Lancaster University, UK He has

a strong interest in risk, safety and professional expertise in anaesthesia andrew f.smith@mbht.nhs.uk

Arnd Timmermann is consultant anaesthetist and co-director of the Centre for

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

eric Thomas is a professor of medicine at the University of Texas – Houston

Medical School and Director of the UT-Houston Memorial Hermann Center for Healthcare Quality and Safety He studies several aspects of patient safety including diagnostic errors, teamwork and safety culture Eric.Thomas@uth.tmc edu

Paul uhlig is a cardiothoracic surgeon and associate professor in the Department

of Preventive Medicine and Public Health at the University of Kansas, School

of Medicine – Wichita in Wichita, Kansas His area of special expertise is social architecture in healthcare and methods for transformation of healthcare practice culture

Shabnam undre is a doctor of medicine and is a trainee in urology She recently

completed her PhD, ‘Teamwork in the Operating Theatre’, at Imperial College and

is involved in various research projects for assessing and improving teamwork in surgery

Charles vincent trained as a clinical psychologist and has conducted research on

risk management, medical error and patient safety in a number of settings He is currently Director of the Centre for Patient Safety and Service Quality at Imperial College Academic Health Sciences Centre c.vincent@imperial.ac.uk

Bart vrouenraets is a surgeon working at the Department of Surgery at Sint

Lucas Andreas Hospital in Amsterdam His specialities are surgical oncology and general surgery bc.vrouenraets@slaz.nl

Johannes Wacker is a board-certified specialist in anaesthesiology FMH and is

working as a consultant anaesthetist at the Department of Anaesthesia, University Hospital Zurich, Zurich, Switzerland johannes.wacker@usz.ch; http://www anaesthesie.usz.ch

Carl-Johan Wallin is senior consultant in anaesthesia and intensive care

medicine, Diplomate of the European Academy of Anaesthesiology (DEAA) and PhD in medical sciences He is Director of Training at the Department of Anaesthesiology and Intensive Care at Karolinska University Hospital Huddinge, and the manager of the Division of Advanced Patient Simulation, Centre for Advanced Medical Simulation at Karolinska in Stockholm, Sweden carl-johan wallin@ki.se

Linda Wauben is an engineer working on her PhD in a collaborative project with

the Erasmus MC and Delft University of Technology focusing on human factors l.s.g.l.wauben@tudelft.nl

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Theo Wehner is a professor and holds the Chair of Work and Organizational

Psychology at the ETH Zurich’s Department of Management, Technology and Economics He specializes in human error, experiences and knowledge management twehner@ethz.ch

Sarah Whyte worked for five years as a research coordinator in the operating

room She is currently a doctoral candidate in English Language and Literature at the University of Waterloo and a doctoral fellow at the Wilson Centre in Toronto, Canada sarah.whyte@utoronto.ca

Yan Xiao is associate professor of anaesthesiology and director for research in

patient safety at University of Maryland He authored over 60 journal articles in the areas of patient safety including coordination, team performance, and technology enhanced performance yxiao@maryland.edu

george Youngson is professor of paediatric surgery at Royal Aberdeen Children’s

Hospital His other interests are surgical education and advising government on healthcare strategy He is chairman of the Patient Safety Board at the Royal College

of Surgeons of Edinburgh ggyrach@abdn.ac.uk

Steven Yule is a lecturer in psychology at the University of Aberdeen with

background training in human factors His research is on psychological aspects

of behaviour and safety in high-risk organizations, especially leadership and non-technical skills in surgery www.abdn.ac.uk/~psy296/dept

enikö Zala-Mezö is work and organizational psychologist, lecturer and researcher at

Zurich University of Applied Sciences, Zurich, Switzerland enikoe.zala@phzh.ch

Charles Vincent

What could a background in psychology, medical error and safety bring to surgery and what would surgeons, anaesthetists and nurses make of patient safety? These were the questions that faced me when I moved, in 2002, from a department of psychology to a department of surgery Initially I read the surgical literature to see how safety was approached The journals were full of descriptions of the complex technicalities of operative procedure and of the influence of co-morbidities and risk factors on patient outcome From the safety point of view, there was pioneering work on human factors and crisis training in anaesthesia and some impressive work on surgical skills However, very little had been written on topics that would appear fundamental to safe surgery such as the nature of error and systems, teamwork, decision-making, the working environment, culture and all the other staples of the safety world It was puzzling, and rather worrying, that the safety point of view and the surgical literature seemed so divergent

Even more puzzling however was that the surgical literature did not seem to accord with the daily experience of clinicians My colleagues were generous in explaining the challenges of their work; I watched and listened Technical issues, risk factors and so on were certainly critical However, their stories of the operating theatre revolved around difficult decisions, equipment problems, teams that just failed to gel, the difficulty of bringing a team together during a crisis, the way the wider hospital impacted on the operating theatre and so on … in fact a litany of classic safety issues None of this appeared to be reflected in the surgical journals

or in surgical research

The chapters in this book mark the huge progress that has been made over the last five years in broadening the scope of research on the factors that create safety in the operating theatre and beyond The issues that nurses, anaesthetists and surgeons have always dealt with, talked about and suffered are now regarded

as worthy of serious study and recognized as being critical to safe care The chapters are, both individually and collectively, extraordinarily rich and it would

be pointless to anticipate the detailed arguments in a foreword However, it is perhaps worth reflecting on some of the major themes of these studies which, to

my mind, underpin the progress that has been made

First, it is worth recalling that studies of clinical work, particularly on error and safety, can arouse considerable suspicion and even hostility between clinicians and researchers In contrast, as the Edinburgh meeting made clear, these research teams are grounded in trust, mutual respect and the desire to work together for safer healthcare This collaborative and optimistic spirit infuses the studies described

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and also, I believe, accounts for the richness and depth of understanding achieved across disciplines

Second, these studies show a considerable sophistication in the development

of measures There is of course due attention to methodology and technical issues, but also recognition of the subtleties of teamwork and that communication does not only have to be recorded but also understood Even silence may have multiple meanings, which will not be apparent to the casual observer A researcher might take years to fully understand this environment and the meaning of such communications, but a team of researchers and clinicians can together reveal the nuances and subtleties

Third, the studies almost all concern safety and yet are not dominated by the issue of error These researchers are concerned to understand how safety is created and eroded in the fluid interplay of clinical work Certainly, both clinicians and researchers need to understand failure and the many hazards of the operating theatre; but the study of failure is in a sense only a necessary step in the more general quest to understand how success is achieved and how safety can be gained

or lost in a moment

Finally, these studies carry lessons beyond their immediate focus Although this book is apparently confined to the operating theatre, it points to much wider themes of relevance to safety in healthcare Many authors speak, directly or indirectly, of the wider influences on teamwork in the operating theatre and the need to address these issues if theatre teams are to reach their full potential These issues include staffing levels, organizational constraints and trade-offs, failure to train in teams, inter-professional rivalries, and the difficulties of engaging staff in safety procedures In this sense the operating theatre, and the mirror these studies hold to it, is a microcosm of the healthcare system If you read this book you will learn a great deal about the operating theatre, but also a great deal about the progress and challenges of patient safety across the whole of healthcare

George Youngson

Since the primitive beginnings of operative surgery, surgeons have had a need

to work with assistance, even if it was, in those early times, merely for the purposes of physical restraint As surgical and anaesthetic practice became more sophisticated, so were the tasks becoming more complex and the demand on the surgical team ever increasing It is only recently, however, with surgery becoming

an ever more complex and technology-based clinical science that the dynamic and interaction between all members of the surgical team has become more important and seen as an element that contributes to a successful outcome or not as the case may be As the severity of illness being treated increases and potency of the therapeutic surgical tools becoming ever greater, so does the risk of the treatment and the potential for harm The safety of patients and their continued well-being while under operative care is therefore not a recent nor novel concern – but there

is a new and increasing recognition of the need for a standardized approach to communication, leadership and teamworking in the operating theatre, if the team

is to work at maximum efficiency and if error of understanding and performance between individual team members is to be avoided

The Royal College of Surgeons of Edinburgh (RCSEd) has a long tradition

of trying to build upon surgical standards of care and to further promote safe surgical practice; it has created a specific forum around which both technical but also nontechnical aspects of operative performance can be researched, discussed and developed The Patient Safety Board of the College has formed out of developmental research on non-technical skills utilized by surgeons during their operative performance Working in concert with the University of Aberdeen and surgeons in Edinburgh, Dundee, Aberdeen and Inverness a more scholastic approach to the recognition, development and teaching of non-technical skills during operative surgery has evolved

The need for a better appreciation of the potential benefits and hazards accruing from interpersonal behaviours and the cognitive performance of the surgeon,

as well as his/her ability to execute the technical tasks with precision and care, requires a different approach, a new way of thinking, a new language and way of speaking

The RCSEd was therefore delighted to play host to this international workshop involving researchers in the human factors involved in surgery from across the globe The college itself had organized the ‘Advancing Patient Safety in Surgery’ (APSIS) conference the previous day, which had set the scene for a paradigm shift

in the way that surgeons lead, follow, communicate, act and think This book is

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therefore a welcome contribution to the understanding of team performance in the operating theatre and how I, as surgeon, can maximize the contributions of those around me, at the same time ensuring my performance is to the best of my abilities

in pursuit of the optimal outcome for my patient

Rhona Flin and Lucy Mitchell

Background

This book is designed to present a state-of-the-art perspective on a new area of psychological and medical research where social scientists are engaged with clinicians in collaborative projects to study surgical teams at work in hospital operating theatres Their goal is to improve understanding of the factors shaping safe and efficient operative performance Given the importance of anaesthetic, theatre nursing and surgical tasks for patient safety during an operation, it is surprising how little scientific investigation of working life has taken place in this domain There are very few reports of the culture and behaviour patterns

in surgical and anaesthesia units, apart from some accounts from sociologists (Bosk 1979, Hindmarsh and Pilnick 2002, Millman 1976), journalists (Ruhlman 2003) and personal recollections from surgeons (e.g Conley 1998, Miller 2009,

Weston 2009) These provide rich descriptions of an unusual workplace, powerful

professional cultures, considerable technical expertise and behaviours not always conducive for patient safety Adverse events for surgical patients are undesirable but do sometimes happen (Manuel and Nora 2005) The Chief Medical Officer for England recently stated:

Surgery has seen rapid improvements in recent years: however errors do still occur Further improvements will need a more detailed understanding of the prevalence of harm, a change in culture and the use of innovative new tools, such as surgical checklists (Donaldson 2008, p 27)

Yet, compared to other high risk industrial settings, hardly any systematic research into workers’ behaviour has been carried out in the hazardous task environment of the operating theatre High risk workplaces do not provide the easiest of research subjects but they are an important domain for psychological research, as Wilpert (1996, p 78) noted:

Psychology in high hazard organizations is an unusual conception, a field which

is only gingerly approached by our discipline It requires a drastic expansion

of received theoretical frameworks and demands incisive steps towards interdisciplinary cooperation Barriers to more intensive involvement exist inside and outside psychology Nevertheless enough theoretical and practical

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– even survival – reasons exist for psychologists not to pass up the challenge of helping to contribute to safety and reliability of high hazard systems.

The chapters in this volume have been prepared by clinicians, research psychologists and other social scientists, working with clinicians in an attempt

to develop our understanding of the behaviours of anaesthetists, surgeons, nurses and co-workers in the operating theatre and their consequences for patients This unique collection is the result of a scientific meeting which was organized by the Industrial Psychology Research Centre of the University of Aberdeen and was sponsored by the Royal College of Surgeons of Edinburgh who hosted the event in November 2007 Research teams who were investigating the behaviour of operating theatre personnel were invited to participate and somewhat to our surprise (having anticipated that only a few UK delegates would take part), representatives from teams based in Australia, Canada, Denmark, Germany, Netherlands, Sweden, Switzerland and the USA also decided to attend Travelling across the world in the middle of the northern winter for a one day meeting in Edinburgh was not possible for all those invited Fortunately, three of the North American teams who could not

be at the meeting, agreed to contribute chapters describing their latest work Our aim in organizing the meeting was to provide an opportunity for researchers

to exchange information on theoretical and methodological approaches suited

to carrying out psychological investigations in the operating theatre, as well as

to share emerging findings The material presented demonstrated the range and quality of some of the most innovative and significant research being conducted

in the service of surgical safety (the original presentations are available on www abdn.ac.uk/iprc) The day was a considerable success with too little time for an adequate exchange or scientific discussion but a tantalizing array of data and methods was revealed In an effort to capture the shared knowledge presented at this first gathering of operating theatre behavioural researchers, we decided (and acknowledge a suggestive email message from Andy Smith, author of Chapter 15)

to produce this edited book

Overview

The chapters to follow represent different conceptual approaches to the study of behaviour in operating theatres and they are typically describing work which has been published very recently or is still in progress In some cases, authors are outlining their ideas for studies that are currently under development They were all encouraged to provide full references to illustrate the supporting evidence for their theories and methods and, where possible, to include examples or sources for the measurement tools they were using to study behaviour

Opening prefaces and closing commentaries have been contributed by surgeons, anaesthetists and psychologists, reflecting the multidisciplinary nature

of the rest of the book In Part I, Chapters 2 to 10 describe the latest research with

new measurement tools that have been designed to record and rate the behaviours and skills of individuals and/ or teams when working in the anaesthetic room or the operating theatre Many of these instruments, being developed for behavioural measurement and training in anaesthesia and surgery, have their roots in aviation practices Part II, consisting of Chapters 11–24, presents a broader range of different kinds of observational studies of theatre teams or individual clinicians

in action during the induction or recovery from anaesthesia or engaged in surgical operations Chapter 25, by Musson, one of the very few physicians with a Ph.D in aviation psychology, offers a cautionary perspective on the risks for medicine of generalizing too readily from the world of aviation

We hope this collection will prove to be a valuable resource for both practitioners and researchers in their endeavours to improve safety for surgical patients

Acknowledgements

We are particularly grateful for the support offered by Professors Rowley and Youngson of the Royal College of Surgeons of Edinburgh in offering to host the first scientific meeting of this new research community A second, and equally beneficial, meeting was held at Oxford University in July 2008, hosted by Mr Peter McCulloch and Dr Ken Catchpole The papers from that meeting are available from: <www surgery.ox.ac.uk/research/qrstu/International%20workshop>

Our thanks go to Guy Loft at Ashgate for all his support and advice during the preparation of this volume, and to all those who contributed chapters; we are specially appreciative of all the expert help we received from Wendy Booth in transforming multiple idiosyncratic interpretations of the Ashgate style manual into a coherent typescript

References

Bosk, C (1979) Forgive and Remember: Managing Medical Failure Chicago:

University of Chicago Press

Conley, F (1998) Walking out on the Boys New York: Farrar, Straus and Giroux Donaldson, L (2008) While you were sleeping Making surgery safer In Chief

Medical Officer’s Report for England and Wales London: Department of

Health, 27–33

Hindmarsh, J and Pilnick, A (2002) The tacit order of teamwork: Collaboration

and embodied conduct in anaesthesia Sociological Quarterly 43, 139–64 Manuel, B and Nora, P (2005) (eds) Surgical Patient Safety Chicago: American

College of Surgeons

Miller, C (2009) The Making of a Surgeon in the 21 st Century Nevada City, CA:

Blue Dolphin