WHAT THIS MEANS AT THE COAL FACE

Dr Ken CatchpoleQuality, Reliability, Safety and Teamwork Unit

Nuffield Department of Surgical SciencesUniversity of Oxford

VIGNETTE 1: NEURO SURGERY

A V-P shunt was being given to a paediatric patient. The scrub nurse was new to the operation, but was being supported by an experienced nurse, and the consultant surgeon was joined by a semi-retired colleague and mentor. The operation did not immediately proceed smoothly, with several problems and stoppages due to equipment problems; the diathermy did not immediately function effectively; the pneumatic hose on the cranial drill was occluded when it was secured to the drapes, and took several minutes to rectify (with the nursing staff first changing several parts of the drill before another nurse solved the problem). The surgeons were also struggling with the equipment, some of which was an inappropriate size for the patient, and since this operation was being performed in another part of the hospital from usual, no alternatives were available. To rinse the incision site for passing the V-P shunt under the skin, the semi-retired surgeon requested saline, but the inexperienced and overloaded scrub nurse, also attending to the needs of the consultant surgeon, accidentally gave the previously used syringe of local anaesthetic (chirocaine). As the surgeon was about to squirt the contents of the syringe onto the incision site, the second (experienced) scrub nurse realised the error and very loudly shouted “No don’t do that”, and the error was captured.

Catchpole, Dale, Hirst, Smith, Giddings (2009). The Safer Theatre Teams Project: Final Report to the Health Foundation

STOP

N

STOP

N

STOP

N

DOES “HF TRAINING” WORK?Was the course

useful?Positive course feedback

Improved teamwork climatet = -2.952, p=0.007

Improved Teamwork Scorest = -2.36, p = 0.02

Reduced Technical Errors (t= 2.989 p = 0.004)

Reduced Procedural Errors (t=4.383, p<0.001)

Were Outcomes Improved?

Length of Stay

Operating Time

Complications

Y Were attitudes changed?

Y Was Behaviour Changed?

YWere working

practices improved?

Y

N

STOP

54 Team members received training

48 Operations studied pre-training55 Operations post-training

McCulloch, P, Mishra, A, Handa, A, Dale, T, Hirst, G, Catchpole, K. (2009). The effects of Aviation-style non-technical skills training on technical performance and outcome in the operating theatre. Quality and Safety in Healthcare.

PRE / POST TEAM TRAINING WITH CHECKLIST

Time out or Stop Check

Pre 57% 47% 0% 40%

Post 60% 75% 63% 66%

Briefing Pre 67% 0% 0% 24%Post 71% 100% 14% 58%

Debriefing Pre 0% 0% 0% 0%Post 29% 80% 0% 32%

Site 1 Site 2 Site 3 All

Catchpole, K, Dale, T, Hirst, G, Smith, P, Giddings, A.(2010). A multi-centre trial of aviation-style training for surgical teams. Journal of Patient Safety

RESULTS: SAFETY ATTITUDES QUESTIONNAIRE

0

10

20

30

40

50

60

70

80

90

100

Teamwork Climate Safety Climate Job Satisfaction Perceptions of Management

Working Conditions

Stress Recognition

Me

an

Dim

en

sio

n S

co

re (%

)

Site 1 Site 2 Site 3

Catchpole, K, Dale, T, Hirst, G, Smith, P, Giddings, A.(2010). A multi-centre trial of aviation-style training for surgical teams. Journal of Patient Safety

DOES “HF TRAINING” WORK?

YES.... BUT....

Usually very well liked Helps to bring safety

into the open Can encourage

improvements in culture Focused on individual

responsibility / action In some cases may lead

to significant performance improvements

Of unregulated quality Non-specific Can be brittle / not

sustainable Limited in scope Evidence of value

limited Cost / Benefit?

Displays & Controls

Biomechanics

Task Design

Anthropometrics

‘Workspace’ Design

Environmental stressors

Cognition & memory

Sensory perception

Organisational processes

FUMBLING FOR THE MENU BUTTON….

Healthcare practitioners have to perform to a high degree of precision in an environment that does not encourage the best human performance.

Application of human factors knowledge will provide the organisations, environments, equipment, tasks and training that will encourage the best human performance.

Technology

People

Organisation Environment

Tasks

Carayon et al. Qual.Saf Health Care 2006, 15 Suppl 1:i50-i58.

SYSTEMIC INFLUENCES ON HUMAN PERFORMANCE

“HUMAN FACTORS”