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 AIMS 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. THE SYSTEMS MODEL OF ERROR Humans: Primary Defense Secondary Defense Last Defense Complex systems: BANG!! are a fundamental component of ANY system are uniquely able to function in uncertainty, and make trade-offs create safety in complex systems are inherently unsafe always function at the limits of capacity require safety to be traded for other aspects of system performance. 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 Catchpole K (2011). Task, Team and Technology Integration in the Paediatric Cardiac Operating Room. Progress in Pediatric Cardiology 32 (2), 85-88. 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 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.” Surgeon Factors Patient Risk Factors + Outcome = Vincent et al: Ann Surg 239(4):475, 2004 THE SYSTEMS PERSPECTIVE Patient Risk Factors “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 Surgical Flow Disruption Factors Technology + Surgeon Factors Supervisory • Equipment design • Maintenance • Training Environment • Scheduling • Distractions • Interruptions Teamwork • Communication • Familiarity Outcome • Staffing Organizational • Procedures • Policies • Resources = 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. 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 New plan not clearly 13:41 Surgeon asks for more calcium. Task conflict; attention elsewhere 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. Fortuitous co-ordination communicated Early Mitigation 13:42 MUF line replaced. P: MUFfing again. S: Give 10. S: Give another 10. 13:43 P & AC make new filtering plan. New plan co-ordinated Catchpole K (2011). Task, Team and Technology Integration in the Paediatric Cardiac Operating Room. Progress in Pediatric Cardiology 32 (2), 85-88. Error goes unnoticed for >120s Minor Problem Types Co-ordination / communication Absence Equipment failure Equipment Configuration failure Patient-sourced procedural difficulties Safety consciousness Unintended effects on patient Equipment / Workspace management Distraction Perfusion difficulties Psychomotor-related surgical error External resource failure Cannulation difficulties Procedure-related Error Vigilance / awareness Team Conflict Perfusion difficulties: technical Expertise / skill failure Planning failure Temperature control difficulties Pre-operative diagnosis failure Psychomotor Error (general) Fault resolution Resource management Psychomotor-related perfusion error External pressures Fatigue Known problem Decision-related surgical error 24 Operations 366 minor problems 29 different types PEDIATRIC CARDIAC SURGERY 0 0.5 1 1.5 2 2.5 3 Mean number per operation 3.5 4 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. Minor Problem Types Distraction Equipment / workspace management failure Safety consciousness Co-ordination / communication Expertise / skill failure 416 minor problems 20 different types Procedure-related Error Equipment Configuration failure Patient-sourced procedural difficulties ORTHOPEDIC SURGERY Equipment failure Vigilance / awareness failure Absence Psychomotor Error (general) Planning failure External resource failure Team Conflict Psychomotor-related surgical error Resource management failure Unintended effects on patient Pre-operative diagnosis failure Decision-related surgical error 0 1 2 3 4 5 6 7 Mean number per operation 8 9 10 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 978-0-75467536-5 Minor Problems Per Operation (Paediatric Cardiac Surgery) 40 "Low" Risk Operations Minor Failures Observed 35 "High" Risk Operations 30 25 20 15 10 5 0 Level 1 Level 2 Level 3 Level 4 Level 6 Operations by Risk Level Catchpole et al. (2006). Identification of systems failures in successful paediatric cardiac surgery. Ergonomics 49(5-6). Minor Problems Per Operation (Paediatric Cardiac Surgery) 40 "Low" Risk Operations Minor Failures Observed 35 "High" Risk Operations Major Failures 30 25 20 15 10 5 0 Level 1 Level 2 Level 3 Level 4 Level 6 Operations by Risk Level Catchpole et al. (2006). Identification of systems failures in successful paediatric cardiac surgery. Ergonomics 49(5-6). MAJOR EVENTS (2003-2009) (NOT WITH A BANG…….) Pediatric Cardiac Orthopaedics Multiple uncertainty leads to teamwork breakdown, and less tibia. Vascular 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 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 ] People prevent catastrophic failures Avoid problems Circumvent poor processes Make TradeOffs Support each other Capture Failures Mitigate errors 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. THE ORTHOPEDIC OPERATING ROOM CN 1A SN Anaesthetic Workstation Pump AC S Drip Catchpole, K (2009). Observing Failures in Successful Orthopaedic Surgery. In L. Mitchell and R Flin (eds), Safer Surgery – Analysing Behaviour in the Operating Theatre. SURGICAL NOTECHS 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. Dimensions Elements Leadership & Management Leadership Maintenance of Standards Planning & Preparation Workload Management Authority & Assertiveness Teamwork & Co-operation Team building & Maintaining Support of others Understanding team needs Conflict solving Problem Solving & Decision Making Definition & Diagnosis Option Generation Risk Assessment Outcome Review Situation Awareness Notice Understand Think Ahead Below Standard (1) Behaviour directly compromises patient safety and effective teamwork. Basic Standard (2) Behaviour in other conditions could directly compromise patient safety and effective teamwork. Standard (3) Behaviour maintains an effective level of patient safety and teamwork. Exceed(4) Behaviour enhances patient safety and teamwork. A model for all other teams. INFLUENCE OF TEAMWORK 16 1 Ineffective Teams Effective Teams 0.99 Intraoperative Performance 14 10 8 6 4 2 0.97 0.96 0.95 0.94 0.93 0.92 0.91 350 0 0.9 Intraoperative Duration (mins) Minor Problems 12 0.98 300 250 200 150 100 50 0 Pediatric Cardiac Surgery Orthopedic Surgery Catchpole et al. Improving patient safety by identifying latent failures in successful operations. Surgery 142(1), ROBOTIC SURGERY 15.00 10.00 5.00 0.00 COM COO EXT TRN EQ ENV PF SDM IC FUMBLING FOR THE MENU BUTTON…. Menu Dial/Button On / Off Button HUMAN FACTORS IN DESIGN Low Control Compatibility High Control Compatibility 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. LESSONS FROM F1 AND AVIATION Technology Training Regimes Process Organisation – Task Allocation – Task sequence – Discipline and composure Teamwork – Leadership – Involvement – Briefing Threat and Error Management – Checklists – Predicting and Planning – Situation Awareness Monitor Ventilator ODA Consultant Anaesthetist Power Anaesthetic Registrar Pump Drain s Pump CCC Reg / Nurse Nurse Nurse Urine Surgeon Multiple specialists Complex tasks Complex interfaces Time pressure Need for accuracy OVERVIEW OF THE NEW PROCESS Prior to Transfer Patient Transfer Sheet obtained from theatre Bedspace & equipment prepared in CCC Technology Transfer Equipment is configured in CCC SAFETY CHECK Information Handover Discussion & Plan Anaesthetist then Surgeon hand over information using Information Transfer Aide Memoir Group discussion SAFETY CHECK Training time = 30 minutes Anticipation of problems Immediate care strategy agreed 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 SUMMARY 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 THANK YOU FOR LISTENING Dr Ken Catchpole Director of Surgical Safety and Human Factors Research Cedars-Sinai Medical Centre Los Angeles [email protected] [email protected] [email protected] SELECTED PUBLICATIONS 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. Pediatric Anesthesia 17(5), 470-478.