Ken Catchpole

The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre

Unintended harm to patients in operating theatres is common. Correlations have been demonstrated between teamwork skills and error rates in theatres. This was a single-institution uncontrolled before–after study of the effects of “non-technical” skills training on attitudes, teamwork, technical performance and clinical outcome in laparoscopic cholecystectomy (LC) and carotid endarterectomy (CEA) operations. The setting was the theatre suite of a UK teaching hospital. Attitudes were measured using the Safety Attitudes Questionnaire (SAQ). Teamwork was scored using the Oxford Non-Technical Skills (NOTECHS) method. Operative technical errors (OTEs), non-operative procedural errors (NOPEs), complications, operating time and length of hospital stay (LOS) were recorded. A 9 h classroom non-technical skills course based on aviation “Crew Resource Management” (CRM) was offered to all staff, followed by 3 months of twice-weekly coaching from CRM experts. Forty-eight procedures (26 LC and 22 CEA) were studied before intervention, and 55 (32 and 23) afterwards. Non-technical skills and attitudes improved after training (NOTECHS increase 37.0 to 38.7, t = −2.35, p = 0.021, SAQ teamwork climate increase 64.1 to 69.2, t = −2.95, p = 0.007). OTEs declined from 1.73 to 0.98 (u = 1071, p = 0.009), and NOPEs from 8.48 to 5.16 per operation (t = 4.383, p<0.001). These effects were stronger in the LC group than in CEA procedures. The operating time was unchanged, and a non-significant reduction in LOS was observed. Non-technical skills training improved technical performance in theatre, but the effects varied between teams. Considerable cultural resistance to adoption was encountered, particularly among medical staff. Debriefing and challenging authority seemed more difficult to introduce than other parts of the training. Further studies are needed to define the optimal training package, explain variable responses and confirm clinical benefit.

Teamwork and Error in the Operating Room : Analysis of Skills and Roles

Objective:To analyze the effects of surgical, anesthetic, and nursing teamwork skills on technical outcomes. Summary Background Data:The value of team skills in reducing adverse events in the operating room is presently receiving considerable attention. Current work has not yet identified in detail how the teamwork and communication skills of surgeons, anesthetists, and nurses affect the course of an operation. Methods:Twenty-six laparoscopic cholecystectomies and 22 carotid endarterectomies were studied using direct observation methods. For each operation, teams’ skills were scored for the whole team, and for nursing, surgical, and anesthetic subteams on 4 dimensions (leadership and management [LM]; teamwork and cooperation; problem solving and decision making; and situation awareness). Operating time, errors in surgical technique, and other procedural problems and errors were measured as outcome parameters for each operation. The relationships between teamwork scores and these outcome parameters within each operation were examined using analysis of variance and linear regression. Results:Surgical (F(2,42) = 3.32, P = 0.046) and anesthetic (F(2,42) = 3.26, P = 0.048) LM had significant but opposite relationships with operating time in each operation: operating time increased significantly with higher anesthetic but decreased with higher surgical LM scores. Errors in surgical technique had a strong association with surgical situation awareness (F(2,42) = 7.93, P < 0.001) in each operation. Other procedural problems and errors were related to the intraoperative LM skills of the nurses (F(5,1) = 3.96, P = 0.027). Conclusions:Detailed analysis of team interactions and dimensions is feasible and valuable, yielding important insights into relationships between nontechnical skills, technical performance, and operative duration. These results support the concept that interventions designed to improve teamwork and communication may have beneficial effects on technical performance and patient outcome.

The Oxford NOTECHS System: reliability and validity of a tool for measuring teamwork behaviour in the operating theatre

Introduction: The frequency of adverse events in the operating theatre has been linked to the quality of teamwork and communication. Developing suitable measures of teamwork may play a role in reducing errors in surgery. This study reports on the development and evaluation of a method for measuring operating-theatre teamwork quality. Methods: The Oxford Non-Technical Skills (NOTECHS) scale was developed from an aviation instrument for assessment of non-technical skills. Consultation with experts and task analysis led to modifications reflecting the complexities of the theatre teamwork, particularly the coexistence of three subteams (surgeons, anaesthetists and nurses). The scale was then evaluated using teams performing laparoscopic cholecystectomy (n = 65) before and after teamwork training. Attitudes to teamwork and surgical error rates were assessed by questionnaire and direct observation methods, and used to assess the reliability and validity of the Oxford NOTECHS scale. Results: The interobserver reliability was excellent in 24 operations independently assessed by two observers (Rwg = 0.99), confirmed by a third observer in 11 cases (Rwg = 0.99). Validity was demonstrated through improved scores after teamwork training (t = −3.019, p = 0.005), concurrent with improved attitudes to teamwork after training; inverse correlation between NOTECHS scores and surgical errors (ρ = −0.267, p = 0.046); strong inverse correlation between surgical subteam score and surgical errors (ρ = −0.412, n = 65, p = 0.001); and strong correlation with teamwork scores from an alternative system (n = 5, r = 0.886, p = 0.046) Conclusion: The Oxford NOTECHS scale appears to be a reliable and valid instrument for assessing teamwork in the operating theatre, and is ready for further application.

Compliance and use of the World Health Organization checklist in U.K. operating theatres.

The World Health Organization (WHO) Surgical Safety Checklist is reported to reduce surgical morbidity and mortality, and is mandatory in the UK National Health Service. Hospital audit data show high compliance rates, but direct observation suggests that actual performance may be suboptimal.

Spreading human factors expertise in healthcare: untangling the knots in people and systems

Human factors (HF) is a term many involved in healthcare delivery are now familiar with, even though a decade ago most had never heard of the concept. The majority of clinicians and healthcare improvement specialists have learned of HF through a particular branch of practice that derived from aviation and arose from the need to address error, teamwork and communication issues. This behavioural safety approach, while entirely legitimate and increasingly well evidenced, is limited. Yet, it has dominated perceptions of what constitutes HF and shaped the application of HF principles in healthcare. Frequently espoused by well meaning clinicians and aviators, rather than academically qualified HF professionals, it has led to misunderstandings about the range of approaches, knowledge, science and techniques that can be applied from the field of HF to address patient safety and quality of care problems. In this issue, Russ et al 1 seek to redress some of the consequences of this misappropriation. They articulate the problems succinctly and expand on earlier calls2 ,3 for greater integration of HF expertise in healthcare. Repeatedly encountering recurrent misunderstandings and misuse of HF undoubtedly concerns academic experts. However, rather than feeling frustration over the ‘fictions’ discussed by Russ et al ,1 HF professionals should be encouraged by the tremendous progress made in recent years—from a state in which clinicians had little exposure to HF work, and even fewer saw its value, to widespread acknowledgement of the value of human-centred systems thinking in healthcare. Yet, the origins of the misunderstandings of HF discussed by Russ et al 1 warrant reflection, as they may signal deeper problems in healthcare and the ways in which HF experts have worked in healthcare. One simple reason for misunderstandings about HF arising so commonly in healthcare may be that the spread of HF principles …

State of science: human factors and ergonomics in healthcare

The past decade has seen an increase in the application of human factors and ergonomics (HFE) techniques to healthcare delivery in a broad range of contexts (domains, locations and environments). This paper provides a state of science commentary using four examples of HFE in healthcare to review and discuss analytical and implementation challenges and to identify future issues for HFE. The examples include two domain areas (occupational ergonomics and surgical safety) to illustrate a traditional application of HFE and the area that has probably received the most research attention. The other two examples show how systems and design have been addressed in healthcare with theoretical approaches for organisational and socio-technical systems and design for patient safety. Future opportunities are identified to develop and embed HFE systems thinking in healthcare including new theoretical models and long-term collaborative partnerships. HFE can contribute to systems and design initiatives for both patients and clinicians to improve everyday performance and safety, and help to reduce and control spiralling healthcare costs. Practitioner Summary: There has been an increase in the application of HFE techniques to healthcare delivery in the past 10 years. This paper provides a state of science commentary using four illustrative examples (occupational ergonomics, design for patient safety, surgical safety and organisational and socio-technical systems) to review and discuss analytical and implementation challenges and identify future issues for HFE.

Factors influencing incident reporting in surgical care

Objectives: To evaluate the process of incident reporting in a surgical setting. In particular: the influence of event outcome on reporting behaviour; staff perception of surgical complications as reportable events. Design: Anonymous web-based questionnaire survey. Setting: General Surgical Department in a UK teaching hospital. Population: Of 203 eligible staff, 55 (76.4%) doctors and 82 (62.6%) nurses participated. Main outcome measures: Knowledge and use of local reporting system; propensity to report incidents which vary by outcome (harm, no harm, harm prevented); propensity to report surgical complications; practical and psychological barriers to reporting. Results: Nurses were significantly more likely to know of the local reporting system and to have recently completed a report than doctors. The level of harm (F(1.8,246) = 254.2, p<0.001), incident type (F(1.9,258) = 64.4, p<0.001) and profession (F(1,135) = 20.7, p<0.001) all significantly affected the likelihood of reporting. Staff were most likely to report an incident when harm occurred. Doctors were significantly less likely to report surgical complications than other types of incident (15% vs 53%, z = 4.633, p<0.001). Fear was a significantly less important barrier to reporting than other reasons (z = −3.49, p<0.0002). Conclusion: An incident is more likely to be reported if harm results. Surgical complications are not generally perceived to be “reportable incidents,” but they are addressed in Mortality and Morbidity meetings (M&M). Integrating M&M and incident reporting data will result in more comprehensive healthcare safety systems.

Interventions employed to improve intrahospital handover: a systematic review

Background Modern medical care requires numerous patient handovers/handoffs. Handover error is recognised as a potential hazard in patient care, and the information error rate has been estimated at 13%. While accurate, reliable handover is essential to high quality care, uncertainty exists as to how intrahospital handover can be improved. This systematic review aims to evaluate the effectiveness of interventions aimed at improving the quality and/or safety of the intrahospital handover process. Methods We searched for articles on handover improvement interventions in EMBASE, MEDLINE, HMIC and CINAHL between January 2002 and July 2012. We considered studies of: staff knowledge and skills, staff behavioural change, process change or patient outcomes. Results 631 potentially relevant papers were identified from which 29 papers were selected for inclusion (two randomised controlled trials and 27 uncontrolled studies). Most studies addressed shift-change handover and used a median of three outcome measures, but there was no outcome measure common to all. Poor study design and inconsistent reporting methods made it difficult to reach definite conclusions. Information transfer was improved in most relevant studies, while clinical outcome improvement was reported in only two of 10 studies. No difference was noted in the likelihood of success across four types of intervention. Conclusions The current literature does not confirm that any methodology reliably improves the outcomes of clinical handover, although information transfer may be increased. Better study designs and consistency of the terminology used to describe handover and its improvement are urgently required.

Integrating Human Factors Research and Surgery: A Review

OBJECTIVE To provide a review of human factors research within the context of surgery. DATA SOURCES We searched PubMed for relevant studies published from the earliest available date through February 29, 2012. STUDY SELECTION The search was performed using the following keywords: human factors, surgery, errors, teamwork, communication, stress, disruptions, interventions, checklists, briefings, and training. Additional articles were identified by a manual search of the references from the key articles. As 2 human factors specialists, a senior clinician, and a junior clinician, we carefully selected the most appropriate exemplars of research findings with specific relevance to surgical error and safety. DATA EXTRACTION Seventy-seven articles of relevance were selected and reviewed in detail. Opinion pieces and editorials were disregarded; the focus was solely on articles based on empirical evidence, with a particular emphasis on prospectively designed studies. DATA SYNTHESIS The themes that emerged related to the development of human factors theories, the application of those theories within surgery, a specific interest in the concept of flow, and the theoretical basis and value of human-related interventions for improving safety and flow in surgery. CONCLUSIONS Despite increased awareness of safety, errors routinely continue to occur in surgical care. Disruptions in the flow of an operation, such as teamwork and communication failures, contribute significantly to such adverse events. While it is apparent that some incidence of human error is unavoidable, there is much evidence in medicine and other fields that systems can be better designed to prevent or detect errors before a patient is harmed. The complexity of factors leading to surgical errors requires collaborations between surgeons and human factors experts to carry out the proper prospective and observational studies. Only when we are guided by this valid and real-world data can useful interventions be identified and implemented.

Human factors and ergonomics and quality improvement science: integrating approaches for safety in healthcare

In this paper, we will address the important question of how quality improvement science (QIS) and human factors and ergonomics (HFE) can work together to produce safer solutions for healthcare. We suggest that there will be considerable advantages from an integrated approach between the two disciplines and professions which could be achieved in two phases. First, by identifying people trained in HFE and those trained in QIS who understand how to work together and second, by developing opportunities for integrated education and training. To develop this viewpoint we will: 1. Discuss and explore how QIS and HFE could be integrated by building on existing definitions, scope of practice, knowledge, skills, methods, research and expertise in each discipline. 2. Outline opportunities for a longer-term integration through training, and education for healthcare professionals. The disciplines and professions of QIS and HFE developed from similar origins in the 20th century to engage workers in the identification of problems and development of solutions.1 ,2 They diverged with QIS focussing more on process issues (eg, production quality control) and HFE focussing on wellbeing (occupational health and safety) and performance. Both have been used in healthcare for many years, with several recent papers discussing confusion about jargon in one or both disciplines.3–7 We will offer a simple outline of our perspectives for each before suggesting an approach for integrated working. We are using the term QIS to include both quality improvement and improvement science.8 QIS is used, defined and explained in the literature in many different ways, for example, ‘the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge’;9 ‘better patient experience and outcomes achieved through changing provider behaviour and organisation through using a systematic change method and strategies’ …