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Task, Team and Technology Integration in Safety and Performance Improvement

Dr Ken Catchpole Director of Surgical Safety and Human Factors Research Department of Surgery Cedars-Sinai Medical Center Los Angeles. Task, Team and Technology Integration in Safety and Performance Improvement. Introduce the concept of human factors

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Task, Team and Technology Integration in Safety and Performance Improvement

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  1. Dr Ken Catchpole Director of Surgical Safety and Human Factors Research Department of Surgery Cedars-Sinai Medical Center Los Angeles Task, Team and Technology Integration in Safety and Performance Improvement

  2. Introduce the concept of human factors Explore what can go wrong in Cardiac and Vascular Surgery Discuss how individual performance can be improved by shaping complex environments. Aims

  3. BANG!! The Systems Model of Error • Humans: • are a fundamental component of ANY system • are uniquely able to function in uncertainty, and make trade-offs • create safety in complex systems • Complex systems: • are inherently unsafe • always function at the limits of capacity • require safety to be traded for other aspects of system performance. Primary Defense Secondary Defense Last Defense

  4. Heparin protocols (Cardiac Surgery) • Initiation of CPB without sufficient heparin is catastrophic (≈ 1 in 750) • Hospital A • Surgeon: Heparin please • Anaesthetist: Okay, heparin • Anaesthetist: Heparin going in • Surgeon: Are we ready to go on bypass? • Anaesthetist: Yes, ready • Perfusionist: Yes, I’m ready • Hospital B: • Surgeon: Okay? • Anaesthetist: Yes • Surgeon: Alright then No recent heparin incidents “It’s fine if you know how we do it here.” “About 6 months ago we had a bit of an incident with someone new, but they weren’t here long.” Cons. Anaesthetist, March 2006 Catchpole K (2011). Task, Team and Technology Integration in the Paediatric Cardiac Operating Room. Progress in Pediatric Cardiology 32 (2), 85-88.

  5. Surgeon Factors Patient Risk Factors Outcome + = The traditional Perspective “Once outcomes (usually mortality) have been correctly adjusted for patient risk factors, the remaining variance is assumed to be explained by individual surgical skill.” Vincent et al: Ann Surg 239(4):475, 2004

  6. Surgical Flow Disruption Factors • Technology • Equipment design • Maintenance Supervisory • Training • Staffing • Scheduling Organizational • Procedures • Policies • Resources Patient Risk Factors = Surgeon Factors Outcome The systems Perspective “Refinements in skill may be a relatively small element in the drive to reduce mortality from 10% to 1%. Optimizing the surgical environment, attention to ergonomics and equipment design, understanding the subtleties of decision making in a dynamic environment, enhancing communication and team performance may be more important than skill when reaching for truly high performance. ” Vincent et al: Ann Surg 239(4):475, 2004 • Environment • Distractions • Interruptions + • Teamwork • Communication • Familiarity

  7. Systemic influences on HUMAN performance Organisation Environment People Tasks Technology “HUMAN FACTORS” Carayon et al. Qual.Saf Health Care 2006, 15 Suppl 1:i50-i58.

  8. New plannot clearly communicated Task conflict; attention elsewhere Fortuitous co-ordination Early Mitigation New plan co-ordinated Error goes unnoticed for >120s Transcript of an exsanguination • 13:39 P: Filtration stopped. AC: What’s the crit? P: 40. AC (to P): I think we ought to continue + discussion of new plan. Meanwhile, surgeon takes the MUF line out. 1A is involved in planning, but thinks the agreement is to concentrate the blood in the pump. • 13:40 1A: got a gas? AC: reads out bloodgas • 13:41 Surgeon asks for more calcium. • S: I took out the MUF line. P: We’ve started filtering again. S: I’m glad I said something. How much volume did you take out? P: Not a lot. • 13:42 MUF line replaced. P: MUFfing again. S: Give 10. S: Give another 10. • 13:43 P & AC make new filtering plan. Catchpole K (2011). Task, Team and Technology Integration in the Paediatric Cardiac Operating Room. Progress in Pediatric Cardiology 32 (2), 85-88.

  9. Minor Problem Types • 24 Operations • 366 minor problems • 29 different types PEDIATRICCARDIAC SURGERY Catchpole, K, Giddings, A, De Leval, M, Peek, G, Godden, P, Utley, M, Gallivan, S, Hirst, G, Dale, T (2006). Identification of systems failures in successful paediatric cardiac surgery. Ergonomics 49(5-6), pp.567-588.

  10. Minor Problem Types • 416 minor problems • 20 different types ORTHOPEDIC SURGERY Catchpole, K (2009). Observing Failures in Successful Orthopaedic Surgery. In L. Mitchell and R Flin (eds), Safer Surgery – Analysing Behaviour in the Operating Theatre. Aldershot: Ashgate. ISBN 978-0-7546-7536-5

  11. Minor Problems Per Operation (Paediatric Cardiac Surgery) Catchpole et al. (2006). Identification of systems failures in successful paediatric cardiac surgery. Ergonomics 49(5-6).

  12. Minor Problems Per Operation (Paediatric Cardiac Surgery) Major Failures Catchpole et al. (2006). Identification of systems failures in successful paediatric cardiac surgery. Ergonomics 49(5-6).

  13. Pediatric Cardiac • Swab causes compression of right coronary artery • Ex-sanguination during post-bypass heamofiltering • Omission of key surgical step • Premature separation from bypass due to breakdown in teamwork • Aortic homograft ruptured during sternotomy • Incorrectly labeled homograft • Difficult management of activated clotting time • Orthopaedics • Multiple uncertainty leads to teamwork breakdown, and less tibia. • Vascular • Saline given instead of heparin • Neuro • Mix-up between local anaesthetic and saline From approx 150 observed operations @ 8 sites [38+24+6 Cardiac; 10+18 Orthopaedic; 20+9 vascular; 6 Neuro; 9 Max Fax; 15?General; 1 Obs & Gyne ] Major Events (2003-2009)(not with a bang…….)

  14. Avoid problems Circumvent poor processes Capture Failures Make Trade-Offs Mitigate errors Support each other People prevent catastrophic failures

  15. Teamwork in the cardiac oR Catchpole K (2011). Task, Team and Technology Integration in the Paediatric Cardiac Operating Room. Progress in Pediatric Cardiology 32 (2), 85-88.

  16. the orthopedic operating Room Catchpole, K (2009). Observing Failures in Successful Orthopaedic Surgery. In L. Mitchell and R Flin (eds), Safer Surgery – Analysing Behaviour in the Operating Theatre.

  17. Mishra, et al. (2009). The Oxford NOTECHS System: reliability and validity of a tool for measuring teamwork behaviour in the operating theatre. Quality and Safety in Healthcare, 18, pp. 104-108. Surgical NOTECHS

  18. Influence of Teamwork Catchpole et al. Improving patient safety by identifying latent failures in successful operations. Surgery 142(1), pp.102-110.

  19. Robotic Surgery

  20. Fumbling for the menu button…. Menu Dial/Button On / Off Button

  21. Human Factors in Design High Control Compatibility Low Control Compatibility

  22. Systemic influences on HUMAN performance Safety Culture Resilience Learning from Accidents Workspace Design Geographical distribution Physical Constraints Organisation Environment People Selection Training Assessment Tasks Technology Task standardization Roles & Rules Prediction & planing Design Procurement Integration “HUMAN FACTORS” Carayon et al. Qual.Saf Health Care 2006, 15 Suppl 1:i50-i58.

  23. Technology Training Regimes Lessons from F1 and Aviation • Process Organisation • Task Allocation • Task sequence • Discipline and composure • Teamwork • Leadership • Involvement • Briefing • Threat and Error Management • Checklists • Predicting and Planning • Situation Awareness

  24. Multiple specialists Complex tasks Complex interfaces Time pressure Need for accuracy

  25. Prior to Transfer Technology Transfer Information Handover Discussion & Plan Patient Transfer Sheet obtained from theatre Bedspace & equipment prepared in CCC Equipment is configured in CCC SAFETY CHECK Anaesthetist then Surgeon hand over information using Information Transfer Aide Memoir SAFETY CHECK Group discussion Anticipation of problems Immediate care strategy agreed Overview of the New Process Training time = 30 minutes

  26. Some challenges • Teamwork • Fluidity • Role Definition • Training • Professional diversity • Recurrence • Expense • Tasks • Surgical complexity • Variation between surgeries • Variation between teams & surgeons • Technology • Piecemeal • Rarely replaced • Storage • Maintenance

  27. People hold the system together Behavior is not as much about ‘free will’ as it is about the influence of the system Considering the mismatches between human and system can generate new ways to improve performance. The way you make change is as important as what you change Summary

  28. Dr Ken Catchpole Director of Surgical Safety and Human Factors Research Cedars-Sinai Medical Centre Los Angeles ken.catchpole@cshs.org ken.catchpole@safersurgery.co.uk Thank you for listening

  29. ken.catchpole@cshs.org Catchpole K. (In Press). Spreading human factors expertise in healthcare: Untangling the knots in people and systems. BMJ Quality and Safety. Accepted 23 March 2013. Catchpole K, Gangi A, Blocker R, Ley E, Blaha J, Gewertz B, Wiegmann D. (2013) Flow disruptions in trauma care handoffs. Accepted to the Journal of Surgical Research, Feb 19th 2013. Catchpole K, Wiegmann D (2012). Understanding safety and performance in the cardiac operating room: from ‘sharp end’ to ‘blunt end’. BMJ Quality and Safety 21(10), 807-809. Catchpole K (2011). Task, Team and Technology Integration in the Paediatric Cardiac Operating Room. Progress in Pediatric Cardiology 32 (2), 85-88. McCulloch, P, Rathbone, J, Catchpole, K, (2011). The effects of interventions to improve teamwork and communications amongst healthcare staff. British Journal of Surgery 98 pp 469-479. 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 6(3),180-186 McCulloch, P, Kreckler, S, New, S, Sheena, Y, Handa, A, Catchpole, K. (2010). Effect of a ‘Lean’ intervention to improve safety process and outcomes on a surgical ward. British Medical Journal. 341:c5469. Catchpole, K, Bell, D, Johnson, S (2008). Safety in Anaesthesia: A study of 12606 reported incidents from the UK National Reporting and Learning System. Anaesthesia 63 340-346. Catchpole, K, Giddings, A, Wilkinson, M, Hirst, G, Dale, T, De Leval, M. (2007) Improving patient safety by identifying latent failures in successful operations. Surgery 142(1), pp.102-110. Catchpole, K, de Leval, M, McEwan, A, Pigott, N, Elliott, M, McQuillan, A, MacDonald, C, Goldman, A (2007). Patient Handover from Surgery to Intensive Care: Using Formula 1 and Aviation Models to Improve Safety and Quality. PediatricAnesthesia17(5), 470-478. Selected publications

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