Safer Surgery

Contents......Page 6
List of Figures......Page 10
List of Tables......Page 12
Notes on Contributors......Page 14
Foreword......Page 24
Preface......Page 26
Rhona Flin and Lucy Mitchell......Page 28
PART I Tools for Measuring Behaviour in the Operating Theatre......Page 32
Steven Yule, Rhona Flin, Nikki Maran, David Rowley, George Youngson, John Duncan and Simon Paterson-Brown......Page 34
David Pitts and David Rowley......Page 54
Joy Marriott, Helen Purdie, Jim Crossley and Jonathan Beard......Page 74
Lucy Mitchell and Rhona Flin......Page 94
Shabnam Undre, Nick Sevdalis and Charles Vincent......Page 110
Ami Mishra, Ken Catchpole, Guy Hirst, Trevor Dale and Peter McCulloch......Page 130
Stephanie Guerlain and J. Forrest Calland......Page 144
Carl-Johan Wallin, Leif Hedman, Lisbet Meurling and Li Felländer-Tsai......Page 156
Connie Dekker-van Doorn, Linda Wauben, Benno Bonke, Geert Kazemier, Jan Klein, Bianca Balvert, Bart Vrouenraets, Robbert Huijsman and Johan Lange......Page 178
PART II Observational Studies of Anaesthetics......Page 200
Ronnie Glavin and Rona Patey......Page 202
Jodi Graham, Emma Giles and Graham Hocking......Page 216
Michaela Kolbe, Barbara Künzle, Enikö Zala-Mezö, Johannes Wacker and Gudela Grote......Page 230
Tanja Manser, Steven K. Howard and David M. Gaba......Page 250
Andrew Smith, Catherine Pope, Dawn Goodwin and Maggie Mort......Page 268
PART III Observation of Theatre Teams......Page 286
Eric Thomas, Karen Mazzocco, Suzanne Graham, Diana Petitti, Kenneth Fong, Doug Bonacum, John Brookey, Robert Lasky and Bryan Sexton......Page 288
Lorelei Lingard, Sarah Whyte, Glenn Regehr and Fauzia Gardezi......Page 310
Gesine Hofinger and Cornelius Buerschaper......Page 328
Ken Catchpole......Page 348
Peter Dieckmann, Marlene Dyrløv Madsen, Silke Reddersen, Marcus Rall and Theo Wehner......Page 366
Nick Sevdalis, Rosamond Jacklin and Charles Vincent......Page 380
Christoph Eich, Michael Müller, Andrea Nickut and Arnd Timmermann......Page 398
Colin F. Mackenzie, Shelly A. Jeffcott and Yan Xiao......Page 412
Nick Sevdalis, Sonal Arora, Shabnam Undre and Charles Vincent......Page 432
PART IV Discussions......Page 448
David Musson......Page 450
Paul Uhlig......Page 464
Nikki Maran and Simon Paterson-Brown......Page 472
Index......Page 478
Figure 2.1	Developing the NOTSS system......Page 37
Figure 2.2	NOTSS skills taxonomy v1.2......Page 44
Figure 2.3	Completed NOTSS rating form......Page 46
Figure 3.1	Total hip replacement PBA T&O curriculum (Pitts et al. 2007)......Page 59
Figure 4.1	Flowchart of the study implementation......Page 79
Figure 7.1	Escalation model of surgical error......Page 131
Figure 7.2	Relationship between minor failures and ranked non-technical skills performance in paediatric cardiac surgery......Page 134
Figure 7.3	Mechanisms of surgical failure......Page 135
Figure 7.4	Oxford NOTECHS scores against OTAS scores for 5 LCs......Page 138
Figure 8.1	The RATE software......Page 151
Figure 8.2	The RATE event-marking software......Page 152
Figure 9.1	A schematic presentation of a structured team decision-making process......Page 160
Figure 10.1	Causes for latent failures leading to adverse events (adapted from Reason 2005)......Page 179
Figure 10.2	TOPplus poster, first version tested during pilot......Page 186
Figure 10.3	Questions asked by team members as indicated on the poster......Page 188
Figure 10.4	Answers given by the team members as indicated on the poster......Page 189
Figure 10.5	Final version of the poster......Page 194
Figure 11.1	Mini CEX trainee assessment, Victoria Infirmary......Page 211
Figure 11.2	Mini CEX competency descriptors......Page 212
Figure 12.1	Intraclass correlations calculated for each component of ANTS......Page 223
Figure 13.1	A taxonomy of explicit and implicit team coordination and heedful interrelating behaviour......Page 237
Figure 14.1	Conceptual framework of adaptive collaborative practice (by Wehner et al. 2000)......Page 253
Figure 14.2	Overview of the observation system for coordination behaviour in anaesthesia crews......Page 256
Figure 14.3	System for data recording: FIT-system (left) and template with observation codes including ‘buttons’ for members of the operating room team (right)......Page 257
Figure 16.1	The predicted relationship between Behavioral Marker Risk Index and post-operative complications and death......Page 299
Figure 18.1	Connection between medical management and the quality of communication......Page 342
Figure 19.1	Video equipment configuration for orthopaedic surgery......Page 351
Figure 19.2	Mean number of minor failures per operation by type......Page 355
Figure 19.3	Failure source model which links observable minor failures (small boxes) and common systemic causes (large boxes)......Page 357
Figure 19.4	Mean rates of threats (top panel) and errors (bottom panel), with 95 percent confidence intervals......Page 358
Figure 19.5	Bland-Altman plot for agreement between two observers......Page 359
Figure 21.1	A model for the study, with the cues that were available to participating surgeons......Page 388
Figure 21.2	Cue utilization across individual surgeons......Page 389
Figure 22.1	Study setting in theatres: infant simulator and anaesthesia work station, anaesthesia nurse (left) and candidate (right) with the mobile ergospirometry unit applied......Page 400
Figure 22.2	Flow chart for simulated scenario and stress measurement......Page 401
Figure 22.3	MetaMax 3B™......Page 402
Figure 22.4	Candidate with mobile and wireless ergospirometry device attached......Page 403
Table 22.1	Reference intervals for plasma and salivary cortisol......Page 405
Figure 22.6	Salivary alpha-amylase and norepinephrine (noradrenaline) in response to stress (Trier Social Stress Test, TSST) (Rohleder et al. 2004)......Page 406
Figure 23.1	Ambulatory electrocardiograms (ECG) and blood pressure (BP) of an anaesthesiologist during elective (top panel) and emergency (lower panel) intubations......Page 418
Figure 23.2	Heart rate (HR) and blood pressure (BP) of an experienced anaesthesiologist obtained by ambulatory monitors (Holler)......Page 419
Table 23.2	Monitors used: number of patients (%) of total n=48 at each level of airway management task urgency. Emergency = <10 mins after admission, semi-emergency < 10–60 mins after admission and elective = > 1 hour after admission......Page 421
Figure 24.1	The distractions–stress ladder......Page 442
Figure 25.1	An iceberg model for observed behaviours......Page 458
Table 2.1	Summary of NOTSS v1.1 evaluation results (see Yule et al. 2008a for detailed results)......Page 43
Table 3.1	PBA domains......Page 57
Table 3.2 Example elements for total hip replacement PBA, taken from T&O curriculum (Pitts et al. 2007)......Page 58
Table 3.3	Global assessment taken from T&O curriculum (Pitts et al. 2007)......Page 60
Table 3.4	Validation worksheet example taken from T&O curriculum (Pitts et al. 2007)......Page 68
Table 4.1	Index procedures within the surgical specialties......Page 77
Table 5.1	Non-technical skill categories examined in the 13 included papers......Page 96
Table 5.2	Examples of scrub nurse interview questions......Page 100
Table 5.3	Interviewee responses categorized as communication......Page 102
Table 6.1	Operative phases and stages of OTAS©......Page 115
Table 6.2	Task completion rates in general surgery (first study) versus urology (second study)......Page 118
Table 7.1	Summary of first iteration of the surgical NOTECHS scoring system......Page 133
Table 7.4	Reliability of Oxford NOTECHS in 14 cases observed independently with third observer......Page 137
Table 9.1	The A-TEAM scale for assessment of individual team behaviour......Page 166
Table 10.1	Overview questionnaire communication and teamwork in operating theatre......Page 184
Table 10.2	Time frame TOPplus project......Page 185
Table 10.4	Duration of the debriefing (in seconds)......Page 190
Table 11.1	The ANTS system: categories and elements......Page 204
Table 13.1	Definitions and examples for categories......Page 238
Table 14.1	Intra-observer agreement over time for the observation system reported at the level of observation categories......Page 258
Table 16.1	Description of domains behavioural markers of team behaviour assessed by the observers......Page 291
Table 16.2	Definitions of measures: patient risk of complications (American Society of Anesthesiologists – ASA – classification), procedure risk (American College of Cardiologists – ACC-score) and outcome (outcome score)......Page 292
Table 16.3	Characteristics of 293 patients and procedures......Page 295
Table 16.4	Description of behavioural markers scores by operative phase, number and percentage of procedures with complication or death, and odds ratios (OR) and 95 per cent confidence intervals (CI) for complication or death for less frequent observation......Page 297
Table 16.5	The association of the Behavioural Marker Risk Index with post-operative complications and death......Page 298
Table 17.1	Definitions of types of communicative failure with illustrative examples and notes......Page 312
Table 18.1	Sample of the sample......Page 333
Table 18.2	Category system ‘Problem solving in a team’......Page 336
Table 18.3	Examples of behavioural markers for evaluating communication in the scenarios used......Page 337
Table 18.4	Items for evaluating medical management (Scenario 1)......Page 338
Table 18.5	Formal characteristics of utterances in the scenarios......Page 339
Table 18.6	Utterances related to team coordination and shared mental models......Page 340
Table 18.7	Utterances related to the team and the problem-solving process......Page 341
Table 19.1	Phases of a typical primary total knee replacement operation......Page 350
Table 19.2	Descriptions and examples of minor failure types......Page 352
Table 20.1	Selected estimations of frequency of prospective memory based situations in medicine (mean count), error proneness of situations (mean %), and valid number of estimations for each situation (n)......Page 374
Table 21.1	Non-technical skills in the first simulation series......Page 391
Table 23.1	Task sequence tracheal intubation where X = cross, SpO2 = O2 saturation, BP = blood pressure, HR = heart rate, IV = intravenous, CO2 = carbon dioxide......Page 420
Table 23.3	Task durations of intubation events. Mean and standard error of duration (in secs) of events in the intubation sequence among 11 elective and 12 emergency tracheal intubation......Page 422