Paul Greig

Lack of standardisation between specialties for human factors content in postgraduate training: an analysis of specialty curricula in the UK

It is well recognised that a significant proportion of errors involving trainee doctors result from failures of non-technical skills (NTS),1 which occur at least as frequently as knowledge and technical errors.2 Regardless of background, all trainees need generic skills of leadership, decision-making, team-working and resource management.3 It might, therefore, be expected that curricula for different specialties would use similar definitions and teaching methods to specify NTS standards. We have performed an analysis of medical training curricula to determine the extent to which different medical specialties set training objectives in NTS, and to seek trends in the prominence with which these skills feature. All hospital-based medical, surgical and critical-care specialties were obtained in mid-2013, along with each curriculums immediate predecessor (where available). The curricula were initially searched for the core keywords ‘non-technical skills’, ‘situational awareness’ and ‘human factors’, as well as a list of secondary keywords (generated by a modified Delphi process) grouped under headings ‘task management’, ‘team working’, ‘situational awareness’ and ‘decision making’. The list was refined over two generations before consensus was reached. Each curriculum …

Failure to perceive clinical events: An under-recognised source of error ☆

INTRODUCTION Attentional focus narrows as individuals concentrate on tasks. Missing an event that would otherwise appear obvious is termed a perceptual error. These forms of perceptual failure are well-recognised in psychological literature, but little attention has been paid to them in medicine. Cognitive workload and expertise modulate risk, although how these factors interplay in practice is unclear. This video-based experiment was designed to explore the hypothesis that perceptual errors affect clinicians. METHODS 142 volunteers with varying levels of experience of adult resuscitation were shown a short video depicting a simulated cardiac arrest. This video included a series of change-events designed to elicit perceptual errors. The experiment was conducted on-line, with participants watching the video and then responding via combinations of open-ended free-text and directed questioning. RESULTS 141 people experienced at least a single perceptual error. Even the most clinically significant event (disconnection of the patients oxygen supply) was missed by three in four viewers. Although expertise was associated with increased likelihood of detecting an occurrence, even highly significant events were missed by up to two thirds of the most experienced observers. DISCUSSION This study demonstrates, for the first time, that perceptual errors occur during healthcare-relevant scenarios at significant levels. Events such as an oxygen malfunction would meaningfully affect patient outcome and, although expertise conferred some advantages, events were still missed more often than not. Data acquisition is fundamental to good-quality situational awareness. These results suggest perceptual error may be a contributor to adverse events in practice.

Fatigue and risk: are train drivers safer than doctors?

As evidence about the effects of fatigue grows, Paul Greig and Rosamund Snow argue that approaches from other industries where safety is critical should be translated into medical culture

Go/no-go decision in anaesthesia: wide variation in risk tolerance amongst anaesthetists

Background. The variability in risk tolerance in medicine is not well understood. Parallels are often drawn between aviation and anaesthesia. The aviation industry is perceived as culturally risk averse, and part of preflight checks involves a decision on whether the flight can operate. This is sometimes termed a go/no‐go decision. This questionnaire study was undertaken to explore the equivalent go/no‐go decision in anaesthesia. We presented anaesthetists with a range of situations in which additional risk might be expected and asked them to decide whether they would proceed with the case. Methods. An electronic questionnaire was distributed to anaesthetic colleagues of all grades in one National Health Service Trust. Eleven scenarios, all drawn from critical incident data, were presented. Participants were invited to consider whether they would proceed, how they would modify their anaesthetic technique, and to predict whether a colleague with similar experience would make the same decision. Textual responses were analysed qualitatively. Results. The scenario response rate was 28%. Consultants were significantly more likely to proceed than trainees. In no scenario was there absolute agreement over whether to proceed, even in scenarios where national guidelines would suggest a case should be cancelled. Thematic analysis suggested a wide variability in what anaesthetists consider acceptable or professional behaviour. Conclusions. It is clear that safety decisions cannot be made in isolation and that clinicians must consider operational requirements, such as throughput, when making a go/no‐go decision. The level of variability in decision‐making was surprising, particularly for scenarios that appeared to go against guidelines.

“I Can Remember Sort of Vivid People…but to Me They Were Plasticine.” Delusions on the Intensive Care Unit: What Do Patients Think Is Going On?

Introduction Patients who develop intensive care unit (ICU) acquired delirium stay longer in the ICU, and hospital, and are at risk of long-term mental and physical health problems. Despite guidelines for patient assessment, risk limitation, and treatment in the ICU population, delirium and associated delusions remain a relatively common occurrence on the ICU. There is considerable information in the literature describing the incidence, suspected causes of, and discussion of the benefits and side-effects of the various treatments for delirium in the ICU. But peer-reviewed patient-focused research is almost non-existent. There is therefore a very limited understanding of the reality of delusions in the intensive care unit from the patient’s point of view. Method A secondary analysis of the original interviews conducted by the University of Oxford Health Experiences Research Group was undertaken to explore themes relating specifically to sleep and delirium. Results Patients describe a liminal existence on the ICU. On the threshold of consciousness their reality is uncertain and their sense of self is exposed. Lack of autonomy in an unfamiliar environment prompts patients to develop explanations and understandings for themselves with no foothold in fact. Conclusion Patients on the ICU are perhaps more disoriented than they appear and early psychological intervention in the form of repeated orientation whilst in the ICU might improve the patient experience and defend against development of side-effects.

Using the experience-based co-design method to design a teaching package

What problems were addressed? The World Health Organization recommends average noise levels in patient care areas no higher than 35 dB, with peaks below 40 dB. In reality, most intensive care units (ICUs) worldwide average 55-60 dB, with peaks up to 120 dB. Staff acclimatise to this, often rationalising high noise levels as necessary because of the equipment and monitoring needs of patients. There is limited awareness that many sources of noise are modifiable, understanding of the patient experience of intensive care is low, and prior to training there is little motivation to implement change. The objective of this training was to facilitate reflection on the patient experience, with a view to enabling selfdirected change to reduce noise levels in the ICU. What was tried? Building on interviews with former ICU patients and ethnographic observations, we used the experience-based co-design method to create a training course to increase knowledge about noise in the ICU. A collaboration between patients, clinical staff, researchers and medical educationalists ensured learning objectives were relevant, practical and of high educational quality. The course combines a multimedia e-learning package and an in situ simulated patient experience that combines a binaural soundtrack of ICU noises with live-action nursing activities. The e-learning takes approximately 20 minutes to complete and individual experiences last 15 minutes, which includes post-experience debriefing. The authenticity of teaching materials is ensured by using real patient experiences and replicating behaviours observed during ethnography sessions. An online self-assessment is included because formative assessment is both motivational and guides onward learning. Assessment points were mapped to course materials using a curriculum blueprint, and participant feedback was used to refine the simulation experience. What lessons were learned? The simulation invoked feelings of worry, fear, stress, confusion and loneliness. This maps well to patient narratives and indicated our simulation had been successful despite only lasting a few minutes. Post-experience debriefing allowed participants to decompress before returning to work. The negative emotional component was intended to prompt staff reflection, as per Kolb’s learning cycle, and proved effective. All 116 participants described the experience as useful, >90% reporting they should do more to improve the environment for their patients. After the experience, 97% of staff indicated they would modify their behaviours, and this appeared to be carried into practice. Noise level monitoring confirmed a perceivable drop of ~4 dB from a baseline of 57.0 to 53.2 dB during the 4-month post-intervention period. We have been unable to incorporate this training into recurring education sessions. The in situ experience is heavily workload dependent, requiring a bed space and members of the education team to be free at an appropriate time. This requires a flexible, imaginative and highly motivated faculty member to deliver training opportunistically; it was therefore difficult to embed. We are now exploring alternative models to enable stand-alone delivery of this innovative training. We have been able to demonstrate that meaningful teaching can be delivered even in a tightly compressed time format, and that this can successfully modify behaviour. This makes this style of teaching practical in a busy unit, but maintaining momentum after the initial wave of interest remains challenging.

Response to letter from Youngson et al.

We thank Professor Youngson et al 1 for their interest in our work2 and their comments calling for greater standardisation in medical non-technical skills (NTS) teaching. We are pleased that Professor Youngson agrees with our conclusion about the need for better cooperation and communication between specialties on how such training and assessment should be carried out. We are also delighted to acknowledge the important work being carried out by the Royal College of Surgeons (Edinburgh) (RCSEd) and the University of Aberdeen on the development of Non-Technical Skills for Surgeons (NOTSS), and are of course aware of the paper by Crossley et al .3 Although much excellent work has been done, we still maintain that more might be done …

0102 Using Augmented Reality In Scientific Posters

Background The increasing ubiquity of ‘smart’ devices opens up new possibilities for presenting data. Technology-enhanced learning is a rapidly evolving field, and much progress is made by finding new use for audio-visual technology. Some of these innovations can be difficult to communicate adequately in the traditional paper-based format required for poster presentation. The use of augmented reality (AR) tags in posters offers intriguing new possibilites for incorporating multimedia resources in scientific posters. Innovation This approach was piloted in our poster ‘Perceptual failure: an underrecognised source of error’. The study on which this poster was based tested for perceptual errors (change- and inattentional-blindness) using video based materials.1 It is known that insight into perceptual errors is very poor,2 and most people do not recognise that they could be vulnerable to these effects until they are demonstrated to them. The poster created to describe this work was therefore designed to incorporate AR tags using the free ‘Aurasma’ app, available on Apple iOS (iTunes store), and Android (Google Play). These tags are easy to design and incorporate, and require very little computing knowledge. The technology has an established user base and tags can be made public or private, and can be time-limited. Improvements Incorporation of AR tags makes for a visually interesting poster that attracts an audience, particularly amongst tech-savvy users. The advantages are that resources can be demonstrated and not simply described. The use of multimedia allows a new freedom to include information that would simply have been impossible previously. Messages AR tags are simple to set up, and require little prior knowledge. The technology is reasonably mature, and the hardware is already highly prevalent. The opportunities afforded by this new innovation offer a wealth of novel applications in data presentation. References Greig P, Higham H, Nobre A. Failure to perceive clinical events: an under-recognised source of error. Resuscitation 2014;85:952–6 Levin DT, Momen N, Drivdahl S. Change blindness blindness: the metacognitive error of overestimating change-detection ability. Vis cogn. 2000;7(3):397–412

0099 The Use Of Eye Tracking With Simulated Monitors: A Case For Standardisation?

Background The clinical environment has been described as an ‘ergonomic nightmare’,1 in part because equipment is poorly standardised across institutions. A survey conducted locally found in excess of 40 different display layouts in anaesthetic and critical-care monitors alone. Monitor layouts were not even standardised within individual theatre suites. It is known from psychology research that familiarity (memory-orientated cueing) speeds response time and accuracy in visual search tasks,2,3 and it is likely that reading values from an unfamiliar display is more mentally taxing than locating equivalent data on a familiar layout. These extra demands are likely to contribute to errors in clinical practice. Methodology Using simulations of a representative sample of the displays recorded in our survey, mixed with some fictional layouts, we are using a mobile eye-tracking system to measure the effect of familiarity on speed, accuracy, and mental workload when using clinical displays. Expected results These data will enable conclusions to be drawn on the effect of using non-standardised clinical monitors. Participants self-rate their familiarity with each display using a visual analogue scale, while their accuracy, time to locate search items, search order, and number/spread of eye-movements are recorded by the eye-tracker. It should also be possible to assess whether professional background or seniority is relevant, and whether participants search for items by colour, expected screen location, or numerical value. Impact Equipment purchases represent significant capital costs for NHS providers, and clinical devices will generally remain in use for several years. Accordingly only the most appropriate devices should be selected, however it is likely that primarily financial motivators drive many of these decisions. We intend that our data will enable better-informed and safety-focussed business cases to be made for new equipment provision. References Reader TW, Flin R, Cuthbertson BH. Communication skills and error in the intensive care unit. Curr Opin Crit Care 2007;13(6):732–6 Summerfield JJ, Lepsien J, Gitelman DR, et alMesulam MM, Nobre AC. Orienting attention based on long-term memory experience. Neuron 2006;49(6):905–16 Summerfield JJ, Rao A, Garside N, Nobre AC. Biasing perception by spatial long-term memory. The Journal Of Neuroscience: The Official Journal Of The Society For Neuroscience 2011;31(42):14952–60

0100 Perceptual Failure: An Under-recognised Source Of Error

Background Situational awareness is a ‘safety-critical’ skill in medicine,1 but attentional focus narrows as individuals concentrate on tasks. Missing an event that would otherwise appear obvious is termed a perceptual error. Individuals greatly overestimate their perceptual reliability.2 These forms of perceptual failure are well recognised in psychological literature, but little attention has been paid to them in medicine. This video-based experiment was designed to explore the hypothesis that perceptual errors affect clinicians. Methods A bespoke video was created using the simulation centre of the OxSTaR Centre, University of Oxford, which incorporated a number of events designed to probe change- and inattentional-blindness. This sequence was based around a simulated adult resuscitation, and the events varied in clinical significance, from the irrelevant (a change in team members’ clothing) to the highly relevant (disconnection of the patient’s oxygen supply). Participants were stratified by resuscitation experience and professional background. Results A clear advantage was seen in favour of the most experienced, who were more likely to notice clinically relevant events (change in CPR provider, appearance of a stethoscope, change in patient airway, disconnection of oxygen supply) although not the irrelevant change in hat colour. The observed trends surprisingly did not reach significance in the case of the oxygen disconnection, although they were significant in the other cases. For all events, even in the expert group, participants were still more likely to miss the event than to see it. Conclusions These data suggest that clinicians are vulnerable to perceptual errors and that, although training confers an advantage, even experts are likely to miss important events when placed in taxing situations. Events such as oxygen malfunction would meaningfully affect patient outcome. Acquisition of accurate data is fundamental to good-quality situational awareness. These results imply perceptual error is a contributor to adverse events in practice. References Vincent C. Patient Safety. 2nd ed. Oxford: Blackwell; 2010 Levin DT, Momen N, Drivdahl S. Change blindness blindness: the metacognitive error of overestimating change-detection ability. Vis cogn 2000;7(3):397–412