What does safe surgery look like? Jonathan Beard Professor of Surgical Education

What does safe surgery look like? Jonathan Beard Professor of Surgical Education

Incidence of Adverse Events in Healthcare 10-15 % patients* 50% surgical 50% in the operating room 50% preventable Most due to human factors: Poor communication Poor teamworking *Vincent BMJ 2001

US airlines: The Scale of the Problem 5 years (2001-2006) = zero US Healthcare: 250-500,000 deaths from medical errors (many procedural) Equivalent to several Boeing 747s crashing every week! 3

Surgical Never Events 1. Procedure on wrong body part or side 2. Correct procedure on the wrong patient 3. Wrong procedure (or wrong implant) on correct patient 4. Foreign body left behind in patient 5. Peri-operative death in ASA 1 patient

National Patient Safety Agency Checklist Plus Five Steps to Safer Surgery: STEP WHAT? WHEN? Step one: Briefing Before start of list Step two: Sign in On arrival of patient Step three: Time out Before start of procedure Step four: Sign out At end of procedure Step five: Debriefing At end of list

Never events continue to occur: Moppett & Moppett All English NHS hospitals surveyed Caseload and Never Events for 2011-2014 742 Never Events, including: Wrong site Wrong implant Retained foreign objects Risk: 1 : 16,423 operations 1 NE per 12.9 operating theatres per year Risk of severe harm: 1 : 238,939 operations

NatSSIPS Sequential Standards 1. Procedural verification and site marking 2. Safety briefing 3. Sign in 4. Time out 5. Prosthesis verification 6. Prevention of retained foreign objects 7. Sign out 8. Debriefing Applies to ALL invasive procedures

NatSSIPS Not just an enhanced checklist: Clear focus on teamwork and human factors Sets multidisciplinary training as a core activity for ALL procedural teams The basis for the creation of Local Safety Standards for Invasive Procedures = LocSSIPs Safety is not just about checklists, teamwork and human factors, it is about checklists AND teamwork AND human factors.. So how do we train in this stuff?

Royal College of Surgeons Procedural Team Training Concept Simulation is expensive and unlikely to avoid never events (although useful for some scenarios) Observational/self-reflective model of team training is more feasible and cost-effective Need an workplace assessment tool (e.g. NOTSS) and a faculty of procedural team training champions Access to existing e-learning resources Interactive face-to-face training Local adaptation (e.g. LocSIPPS) is fine but not a good idea for every hospital to reinvent the wheel

Learning Resources FOCUS ON RESULTS ACCOUNTABILITY H P COMMITMENT TO THE TASK CONSTRUCTIVE IN CONFLICT HIGH DEGREE OF TRUST The high performing surgical team: RCSEng 2014

TeamSTEPPS Strategies and Tools to Enhance Performance and Patient Safety SBAR Call out and check back Two challenge rule and CUS Formal handover (I pass the baton) www.ahrq.gov/sites/default/publications/files/pocketguide.pdf

Non-Technical Skills (Human Factors) Situational Awareness Decision Making Communication & Teamwork Leadership http://chfg.org/learning-resources/ 13

Taking Personal Responsibility Hungry Angry Late = HALT! Tired Eight times more likely to have an accident

Assessment Methods Oxford NOTECHS derived from methodology used to assess pilots non-technical skills as part of Crew resource management (CRM) training Imperial College Observational Teamwork Assessment for Surgery (OTAS) originally designed for simulated team training research Royal Cornwall Hospitals Team Self-Review (TSR) Assessment methods developed by University of Aberdeen and RCSEd: NOTSS Non-Technical Skills of Surgeons ANTS Anaesthetists Non-Technical Skills SPLINTS Scrub Practitioners List of Intra-operative Non-Technical Skills

Theatre Team Performance Evaluation Exerciseraters - Cognitive skills Watch the following scenario unfold in the operating room Write down any good or poor behaviours by the members of the theatre team that you observe How do the observed behaviours affect the team performance?

What Were Your Observations and Ratings? Were the team prepared for the operation? Did the consultant lead the team well? How well did he supervise/support his trainee and other team members? What about the performance of the other members of the team? How did the consultant s behaviour affect the performance of the team? What can they do to improve things?

Improving team performance requires a change of culture because Culture will trump standards every time Don Berwick Role clarity (own and others) Effective leadership designated and situational role modelling essential Common understanding of task / goal Human factors and team training Managing workload and task coordination Regular debrief / evaluation / assessment

Summary WHO, NPSA and NatSIPPS enhanced checklists can reduce the risk of adverse events Training in human factors improves team performance and morale Individuals must also take personal responsibility Regular assessment (self and team) necessary to change the culture Training in all these aspects must be mandatory for all theatre staff