Nick Sevdalis

Patient involvement in patient safety: what factors influence patient participation and engagement?

Background Patients can play an important role in improving patient safety by becoming actively involved in their health care. However, there is a paucity of empirical data on the extent to which patients take on such a role. In order to encourage patient participation in patient safety we first need to assess the full range of factors that may be implicated in such involvement.

Measuring intra-operative interference from distraction and interruption observed in the operating theatre

An observational tool was developed to record distraction and interruption in the operating theatre during surgery. Observed events were assigned to pre-defined categories and rated in relation to the level of team involvement – the sum of which was treated as a measure of intra-operative interference. Many events (0.29 ± 0.02 per min) were observed and rated in 50 general operations sampled from a single operating theatre. The rating of individual events (r s = 0.65) and of cases (r s = 0.89) correlated between independent observers. Interference levels (1.04 ± 0.07/min) also correlated with door opening frequency (0.68 ± 0.03/min) (r = 0.47, p < 0.001). Some sources of interference were intrinsic to the work of the surgical team, including equipment, procedure and environment, while others were extraneous, including bleepers, phone calls and external staff. The findings highlight the need to further develop measures of interference, to assess its variation, intensity and its effect on surgical team performance.

Reliability of a revised NOTECHS scale for use in surgical teams

BACKGROUNDnRecent developments in the surgical literature highlight the need for assessment of nontechnical skills in surgery. We report a revision of the NOn-TECHnical Skills (NOTECHS) scale of the aviation industry for use in surgery and detailed analysis on its reliability.nnnMETHODSnThe original NOTECHS scale assesses (1) Cooperation, (2) Leadership and Managerial Skills, (3) Situation Awareness and Vigilance, and (4) Decision Making. We added a Communication and Interaction dimension and adapted all subscales for use in surgical context. Reliability was assessed in simulation-based training for trainee clinicians.nnnRESULTSnSatisfactory reliability (Cronbachs alpha) was obtained (1) across professional groups and trainers and trainees, (2) in separate analyses for trainers and trainees, (3) in successive administrations of the scale, and (4) in surgical, anaesthetic and nursing groups analyzed separately. In the operating department practitioners group, Situation Awareness and Vigilance and Cooperation and Team Skills exhibited lower reliability.nnnCONCLUSIONSnAssessment of surgical nontechnical skills is becoming a training priority. The present evidence suggests that the revised NOTECHS scale exhibits good reliability. Further empirical research should assess the validity of the scale.

Multidisciplinary crisis simulations: the way forward for training surgical teams.

BackgroundHigh-reliability organizations have stressed the importance of nontechnical skills for safety and of regularly providing such training to their teams. Recently safety skills training has been applied in the practice of medicine. In this study, we developed and piloted a module using multidisciplinary crisis scenarios in a simulated operating theatre to train entire surgical teams.MethodsTwenty teams participated (nxa0=xa080); each consisted of a trainee surgeon, anesthetist, operating department practitioner (ODP), and scrub nurse. Crisis scenarios such as difficult intubation, hemorrhage, or cardiac arrest were simulated. Technical and nontechnical skills (leadership, communication, team skills, decision making, and vigilance), were assessed by clinical experts and by two psychologists using relevant technical and human factors rating scales. Participants received technical and nontechnical feedback, and the whole team received feedback on teamwork.ResultsTrainees assessed the training favorably. For technical skills there were no differences between surgical trainees’ assessment scores and the assessment scores of the trainers. However, nurses overrated their technical skill. Regarding nontechnical skills, leadership and decision making were scored lower than the other three nontechnical skills (communication, team skills, and vigilance). Surgeons scored lower than nurses on communication and teamwork skills. Surgeons and anesthetists scored lower than nurses on leadership.ConclusionsMultidisciplinary simulation-based team training is feasible and well received by surgical teams. Nontechnical skills can be assessed alongside technical skills, and differences in performance indicate where there is a need for further training. Future work should focus on developing team performance measures for training and on the development and evaluation of systematic training for technical and nontechnical skills to enhance team performance and safety in surgery.

Observational Teamwork Assessment for Surgery (OTAS): Refinement and Application in Urological Surgery

BackgroundTeamwork in surgical teams is at the forefront of good practice guidelines and empirical research as an important aspect of safe surgery. We have developed a comprehensive assessment for teamwork in surgery—the Observational Teamwork Assessment for Surgery (OTAS)—and we have tested it for general surgical procedures. The aim of the research reported here was to extend the assessment to urology procedures.MethodsAfter refining the original assessment, we used it to observe 50 urology procedures. The OTAS comprises a procedural task checklist that assesses patient, equipment/provisions, and communication tasks as well as ratings on five team behavior constructs (communication, cooperation, coordination, leadership, and monitoring). Teamwork was assessed separately in the surgical, anesthesia, and nursing subteams in the operating theater. We also assessed the reliability of the behavioral scoring.ResultsRegarding task completion, a number of communication and equipment/provisions tasks were not routinely performed during the operations we observed. Regarding teamwork-related behaviors, adequate reliability was obtained in the scoring of behaviors. Anesthetists and nurses obtained their lowest scores on communication. Surgeons’ scores revealed a more complex pattern. In addition to low scores on communication, surgeons’ teamwork behaviors appeared to deteriorate as the procedures were finishing.ConclusionsOur findings suggest that OTAS is applicable to various branches of surgery. Separate assessment of the subteams in the operating theater provides useful information that can be used to build targeted teamwork training aiming to improve surgical patients’ safety and outcomes.

Annoyances, Disruptions, and Interruptions in Surgery: The Disruptions in Surgery Index (DiSI)

BackgroundRecent studies have investigated disruptions to surgical process via observation. We developed the Disruptions in Surgery Index (DiSI) to assess operating room professionals’ self-perceptions of disruptions that affect surgical processes.MaterialsThe DiSI assesses individual issues, operating room environment, communication, coordination/situational awareness, patient-related disruptions, team cohesion, and organizational issues. Sixteen surgeons, 26 nurses, and 20 anesthetists/operating departmental practitioners participated. Participants judged for themselves and for their colleagues how often each disruption occurs, its contribution to error, and obstruction of surgical goals.ResultsWe combined the team cohesion and organizational disruptions to improve reliability. All participants judged that individual issues, operating room environment, and communication issues affect others more often and more severely than one’s self. Surgeons reported significantly fewer disruptions than nurses or anesthetists.ConclusionAlthough operating room professionals acknowledged disruptions and their impact, they attributed disruptions related to individual performance and attitudes more to their colleagues than to themselves. The cross-professional discrepancy in perceived disruptions (surgeons perceiving fewer than the other two groups) suggests that attempts to improve the surgical environment should always start with thorough assessment of the views of all its users. DiSI is useful in that it differentiates between the frequency and the severity of disruptions. Further research should explore correlations of DiSI-assessed perceptions and other observable measures.

Mapping surgical practice decision making : an interview study to evaluate decisions in surgical care

BACKGROUNDnTraining surgeons in vital decision-making skills remains unstructured. We aimed to map a process of care from the perspective of surgical decision making and test whether it could be deconstructed into an accessible format for trainees.nnnMETHODSnSemistructured interviews were conducted with 10 experienced surgeons by using symptomatic gallstones as a clinical exemplar. Data were analyzed by 2 independent reviewers to identify decisions, cues, and decision rules, with further thematic analysis of selected decisions.nnnRESULTSnEighteen specific decisions were identified in 6 or more transcripts, with significant interreviewer reliability (Spearmans rho = .65, P = .004, n = 17, 1 outlier excluded). These were arranged to form a decision map. Two main decision strategies were described.nnnCONCLUSIONSnWe identified and mapped the decisions made in the care of patients with symptomatic gallstone disease. The interpretation of competency at any procedure should include the surgeons ability to make appropriate decisions at all stages of patient care.

The complexity of measuring interprofessional teamwork in the operating theatre

Surgery depends on interprofessional teamwork, which is becoming increasingly specialized. If surgery is to become a highly reliable system, it must adapt and professionals must learn from, and share, tested models of interprofessional teamwork. Trainers also need valid measures of teamwork to assess individual and team performance. However, measurement and assessment of interprofessional teamwork is lacking and interprofessional team training is scarce in the surgical domain. This paper addresses the complexity of measuring interprofessional teamwork in the operating theatre. It focuses mainly on the design and properties of observational assessment tools. The report and analysis serves to inform the researcher or clinician of the issues to consider when designing or choosing from alternative measures of team performance for training or assessment.

Biased Forecasting of Postdecisional Affect

Although anticipated postdecisional regret is a significant contributor to peoples decision-making processes, the accuracy of peoples regret forecasts has yet to be assessed systematically. Here we report two studies to fill this lacuna. In Study 1, we found that subjects who made reasonably high offers overpredicted the regret that they experienced after they unexpectedly failed at a negotiation. In Study 2, we found that subjects overpredicted the rejoicing and marginally underpredicted the regret that they experienced when they received higher marks than they had expected for their course work. Systematic affective misprediction implies that people making decisions should discount the regret and rejoicing that they anticipate will be associated with potential outcomes arising from those decisions.

Predicting preferences: a neglected aspect of shared decision-making

In recent years, shared decision‐making between patients and doctors regarding choice of treatment has become an issue of priority. Although patients’ preferences lie at the core of the literature on shared decision‐making, there has not been any attempt so far to link the concept of shared decision‐making with the extensive behavioural literature on peoples self‐predictions of their future preferences. The aim of the present review is to provide this link. First, we summarize behavioural research that suggests that people mispredict their future preferences and feelings. Secondly, we provide the main psychological accounts for peoples mispredictions. Thirdly, we suggest three main empirical questions for inclusion in a programme aimed at enriching our understanding of shared decision‐making and improving the procedures used for putting it into practice.