Doctors' Handovers in an Acute Medical Assessment Unit: A Hierarchical Task Analysis

Doctors' shift handovers have not been well documented, so handovers in an acute medical assessment unit (AMAU) were examined by conducting a hierarchical task analysis (HTA). To construct the HTA, activities doctors engaged in pre-handover, during handover, and post-handover were observed. Interviews and a focus group were also conducted to create the HTA. Findings showed that there are critical tasks that should be completed at each phase of the handover process. But these were sometimes omitted, especially in the pre-handover stage, resulting in extended or delayed handover meetings. Doctors believed that various safety nets were in place to catch any omitted information. Post-handover activities involved prioritizing tasks. However, doctors who had received handover believed that their period of responsibility and accountability for transferred patients was likely to be too short, and therefore expressed that prioritizing tasks for every patient was inefficient. Future research should examine handovers in the context of organizational resilience, and include other clinical staff that influence the information provided at handover.

Thinking Ahead of the Surgeon: Developing a Behavioural Rating System for Scrub Practitioners' Non-Technical Skills (SPLINTS)

Efforts to reduce adverse event rates in healthcare have revealed the importance of identifying the essential non-technical (cognitive and social) skills for safe and effective performance and developing tools for rating and training those skills. The focus of studies to date has been surgeons, anaesthetists, or the whole team, with less attention paid to other professionals. The aim of the study was to develop a behavioural rating system for non-technical skills of the scrub practitioner (nurse/technician). This paper reports an interview study, as part of a task analysis, to identify the critical non-technical skills for this role, and the development of a prototype behavioural rating system. Experienced scrub practitioners (n = 25) and consultant surgeons (n = 9), from four Scottish teaching hospitals, were interviewed using a semi-structured design. Data that described generic non-technical skills were extracted from the interview transcripts and thereafter, psychologists and panels of perioperative practitioners (n = 4) used an iterative process to develop a skills taxonomy. Three categories of non-technical skills were identified as critical for safe and effective scrub practitioner performance. These were; situation awareness, communication and teamwork, task management. Three underlying skill elements for each of the three categories were labeled by the expert panels and they provided examples of good and poor behaviours for each of these skill elements, drawing on their domain knowledge. The reliability and psychometric properties of the prototype skills taxonomy and behaviour rating system are currently being tested using standardized, simulated scenarios.

A preliminary investigation of surgeons' leadership in the operating room

Background: There is widespread recognition that non-technical skills, including leadership, are essential for an effective, efficient and safe team performance. However, the empirical literature on specific skills required for effective leadership within the intraoperative setting is limited and inconclusive. Method: Observations ( n = 23 operations) were conducted in operating rooms (OR) from three teaching hospitals in Scotland to gather data on intraoperative leadership behaviours. This analysis focused on the role of the lead surgeon. These were coded according to a task- and team-oriented structure, using seven leadership constructs identified in the surgical literature. Results: Leadership behaviours were categorised with acceptable inter-rater reliability. The analysis showed that as intraoperative leaders, surgeons exhibited both task- and team-oriented behaviours. They most frequently engaged in team-oriented leadership behaviours, namely ‘guiding and supporting’ followed by ‘communication and coordination’ behaviours. Discussion: This study is the first step in developing an empirically derived scale to measure and evaluate surgeons' intraoperative leadership. Future studies will investigate the relationship between the leadership behaviours identified here, team performance, and patient safety outcomes. Better understanding of intraoperative leadership can lead to improved surgical team performance, which could impact patient safety in the operating room.

Tracing the foundations of a conceptual framework for a patient safety ontology

BACKGROUND

In work for the World Alliance for Patient Safety on research methods and measures and on defining key concepts for an International Patient Safety Classification (ICPS), it became apparent that there was a need to try to understand how the meaning of patient safety and underlying concepts relate to the existing safety and quality frameworks commonly used in healthcare.

OBJECTIVES

To unfold the concept of patient safety and how it relates to safety and quality frameworks commonly used in healthcare and to trace the evolution of the ICPS framework as a basis of the electronic capture of the component elements of patient safety.

CONCLUSION

The ICPS conceptual framework for patient safety has its origins in existing frameworks and an international consultation process. Although its 10 classes and their semantic relationships may be used as a reference model for different disciplines, it must remain dynamic in the ever-changing world of healthcare. By expanding the ICPS by examining data from all available sources, and ensuring rigorous compliance with the latest principles of informatics, a deeper interdisciplinary approach will progressively be developed to address the complex, refractory problem of reducing healthcare-associated harm.

Anaesthetists' non-technical skills

This review presents the background to the development of the anaesthetists' non-technical skills (ANTS) taxonomy and behaviour rating tool, which is the first non-technical skills framework specifically designed for anaesthetists. We share the experience of the anaesthetists who designed ANTS in relation to applying it in a department of anaesthesia, using it in a simulation centre, and the process of introducing it to the profession on a national basis. We also consider how ANTS is being applied in relation to training and research in other countries and finally, we discuss emerging issues in relation to the introduction of a non-technical skills approach in anaesthesia.

Patient safety in surgery: non-technical aspects of safe surgical performance

The performance of operative surgery has an understandable focus placed on dexterity, technical precision, as well as the choice of procedure. There is less appreciation of the cognitive and social skills of the individual surgeon and the effect that these have on the surgical team and on patient outcome. This article highlights that impact and explores the contribution of non-technical skills to safe practice within the operating room.

No simple fix for fixation errors: cognitive processes and their clinical applications

Fixation errors occur when the practitioner concentrates solely upon a single aspect of a case to the detriment of other more relevant aspects. These are well recognised in anaesthetic practice and can contribute significantly to morbidity and mortality. Improvement in patient safety may be assisted by development and application of countermeasures to fixation errors. Cognitive psychologists use 'insight problems' in a laboratory setting, both to induce fixation and to explore strategies to escape from fixation. We present some results from a series of experiments on one such insight problem and consider applications that may have relevance to anaesthetic practice.

Year 1 medical undergraduates' knowledge of and attitudes to medical error

CONTEXT

To improve patient safety, medical students should be taught about human error and the factors influencing adverse events. The optimal evaluation of new curricula for patient safety requires tools for baseline measurement of medical students' attitudes and knowledge.

OBJECTIVES

The aim of the study was to design and evaluate a questionnaire for measuring the attitudes of Year 1 medical students to patient safety and medical error.

METHODS

A questionnaire entitled 'Medical Students' Patient Safety Questionnaire (Year 1)' was designed to assess Year 1 medical students' attitudes and anticipated behaviours relating to medical error and patient safety. This was administered to two cohorts of Year 1 medical students in a UK medical school during 2008 (n = 296) and the data subjected to psychometric analyses.

RESULTS

Medical students' attitudes to good patient safety practices were generally positive, but the students had little knowledge of how to report errors and were unsure about what to do if a colleague made an error or if a patient indicated that an error had been made. On the five scales of the questionnaire, Cronbach's alpha values ranged from 0.59 (Attitudes to patient safety scale) to 0.88 (Knowledge of error and patient safety scale) and three scales showed internal consistencies below the recommended value of 0.70. Exploratory factor analysis showed that the five factors explain 51.7% of variance.

CONCLUSIONS

With some minor item trimming and re-allocation, the Medical Students' Patient Safety Questionnaire (Year 1) can function as an instrument with which to assess the attitudes of new medical students to patient safety and medical error. To assess the suitability of the instrument beyond the UK would require additional work.

Detection of adverse events in a Scottish hospital using a consensus-based methodology

OBJECTIVE

To determine, using a consensus based methodology, the rate and nature of adverse events (AEs) among patients admitted to acute medicine, acute surgery and obstetrics in a large teaching hospital in Scotland.

METHODS

Retrospective case-note review of 450 medical, nursing and medication records to identify and classify adverse events. For 354 patients whose length of stay was greater than 24 hours, the overall adverse event rate was 7.9% which ranged from 0% in obstetrics, 7.2% in acute medicine to 13% in acute surgery. Among all AEs, 43% were deemed preventable by a consensus group and 59% of the AEs contributed to a proportion of the patients' hospital stay or led to hospital readmission. Whilst nurse identification of adverse events was highly specific (94%), its sensitivity was poor (43%). Only 10% of the identified AEs were identified by the hospital's voluntary reporting system for adverse events. The estimated additional cost of adverse events in terms of bed days was ł69,189 which if extrapolated Scotland-wide could cost ł297 million per annum.

CONCLUSIONS

This study supports the need to continue the traditional retrospective record review to identify adverse events. The current hospital-based reporting of adverse events does not provide a complete measure of adverse events and needs to be complemented by other measures.

Non-technical skills of the operating theatre scrub nurse: literature review

AIM

This paper is a report of a review to identify the non-technical (cognitive and social) skills used by scrub nurses.

BACKGROUND

Recognition that failures in non-technical skills contributed to accidents in high-risk industries led to the development of research programmes to study the role of cognition and social interactions in operational safety. Recently, psychological research in operating theatres has revealed the importance of non-technical skills in safe and efficient performance. Most of the studies to date have focused on anaesthetists and surgeons.

DATA SOURCES

On-line sources and university library catalogues, publications of the Association for Perioperative Practice, National Association of Theatre Nurses and Association of Peri-Operative Registered Nurses were searched in 2007.

REVIEW METHODS

Studies were included in the review if they presented data from scrub nurses on one or more of their non-technical skills. These findings were examined in relation to an existing medical non-technical skills framework with categories of communication, teamwork, leadership, situation awareness and decision-making.

RESULTS

Of 424 publications retrieved, 13 were reviewed in detail. Ten concerned communication and eight of those also had data on teamwork. In 11 papers teamwork was examined, and one focused on nurses' situation awareness, teamwork and communication. None of the papers we reviewed examined leadership or decision-making by scrub nurses.

CONCLUSION

Further work is needed to identify formally the non-technical skills which are important to the role of scrub nurse and then to design training in the identified non-technical skills during the education and development of scrub nurses.

Healthcare CEOs' Leadership Style and Patient Safety

Concern about patient safety in healthcare has generally concentrated on the clinical actions and behaviors of the front line staff, those at the so-called ‘sharp end’ or operational level of the institution who provide direct patient care. Workers and their supervisors receive the most scrutiny due to their proximity to adverse events and many interventions, for example training and error/incident reporting systems are targeted at this level of staff. Cultural assessment tools also often focus exclusively on direct care providers. What is frequently overlooked is the role of senior leaders (e.g. Chief Executive Officer (CEO)) and the influence their style and priorities can have on patient safety. This study presents some of the first data on healthcare CEOs' leadership style with respect to patient safety in the United Kingdom (UK) and Canada. We found that transformational leadership and contingent reward were significantly correlated with perceptions of safety climate at executive director level. Furthermore, healthcare CEOs who routinely prioritized patient safety were rated significantly higher on safety climate by the executive directors who report to them.

Surgeons' non-technical skills in the operating room: reliability testing of the NOTSS behavior rating system

BACKGROUND

Previous research has shown that surgeons' intraoperative non-technical skills are related to surgical outcomes. The aim of this study was to evaluate the reliability of the NOTSS (Non-technical Skills for Surgeons) behavior rating system. Based on task analysis, the system incorporates five categories of skills for safe surgical practice (Situation Awareness, Decision Making, Task Management, Communication & Teamwork, and Leadership).

METHODS

Consultant (attending) surgeons (n = 44) from five Scottish hospitals attended one of six experimental sessions and were trained to use the NOTSS system. They then used the system to rate consultant surgeons' behaviors in six simulated operating room scenarios that were presented using video. Surgeons' ratings of the behaviors demonstrated in each scenario were compared to expert ratings ("accuracy"), and assessed for inter-rater reliability and internal consistency.

RESULTS

The NOTSS system had a consistent internal structure. Although raters had minimal training, rating "accuracy" for acceptable/unacceptable behavior was above 60% for all categories, with mean of 0.67 scale points difference from reference (expert) ratings (on 4-point scale). For inter-rater reliability, the mean values of within-group agreement (r (wg)) were acceptable for the categories Communication & Teamwork (.70), and Leadership (.72), but below a priori criteria for other categories. Intra-class correlation coefficients (ICC) indicated high agreement using average measures (values were .95-.99).

CONCLUSIONS

With the requisite training, the prototype NOTSS system could be used reliably by surgeons to observe and rate surgeons' behaviors. The instrument should now be tested for usability in the operating room.

Patient safety: helping medical students understand error in healthcare

OBJECTIVE

To change the culture of healthcare organisations and improve patient safety, new professionals need to be taught about adverse events and how to trap and mitigate against errors. A literature review did not reveal any patient safety courses in the core undergraduate medical curriculum. Therefore a new module was designed and piloted.

DESIGN

A 5-h evidence-based module on understanding error in healthcare was designed with a preliminary evaluation using self-report questionnaires.

SETTING

A UK medical school.

PARTICIPANTS

110 final year students.

MEASUREMENTS AND MAIN RESULTS

Participants completed two questionnaires: the first questionnaire was designed to measure students' self-ratings of knowledge, attitudes and behaviour in relation to patient safety and medical error, and was administered before and approximately 1 year after the module; the second formative questionnaire on the teaching process and how it could be improved was administered after completion of the module.

CONCLUSIONS

Before attending the module, the students reported they had little understanding of patient safety matters. One year later, only knowledge and the perceived personal control over safety had improved. The students rated the teaching process highly and found the module valuable. Longitudinal follow-up is required to provide more information on the lasting impact of the module.

How do surgeons make intraoperative decisions?

Surgeons' intraoperative decision making is a key element of clinical practice, yet has received scant attention in the surgical literature. In recent years, serial changes in the configuration of surgical training in the UK have reduced the time spent by trainees in the operating theatre. The opportunity to replace this lost experience with active teaching of decision making is important, but there seem to have been very few studies that have directly examined the cognitive skills underlying surgical decision making during operations. From the available evidence in surgery, and drawing from research in other safety-critical occupations, four decision-making strategies that surgeons may use are discussed: intuitive (recognition-primed), rule based, option comparison and creative. Surgeons' decision-making processes should be studied to provide a better evidence base for the training of cognitive skills for the intraoperative environment.

Teaching surgeons about non-technical skills

BACKGROUND

Analyses of adverse events in surgery reveal that underlying causes are often behavioural, such as communication failures, rather than technical. Non-technical (i.e. cognitive and interpersonal) skills, whilst recognised, are not explicitly addressed in surgical training. However, surgeons need to demonstrate high levels of these skills, as well as technical proficiency, to maximise safety and quality in the operating theatre. This article describes a prototype training course to raise surgeons' awareness of non-technical skills.

METHODS

The course syllabus was based on a new taxonomy of surgeons' non-technical skills (NOTSS) which has four principal categories: situation awareness, decision-making, communication and teamwork, and leadership. Three, one-day training courses were attended by 21 surgeons.

RESULTS

All surgeons reported that they found explicit review and discussion of these skills and component behaviours helpful for self-reflection. They rated the content as interesting and relevant and the majority declared their intention to make some changes to their behaviour during surgery.

CONCLUSIONS

It was concluded that this type of training could enhance the surgical training portfolio and should be an integral feature of the development and assessment of operative skills.

Interdisciplinary communication in the intensive care unit

BACKGROUND

Patient safety research has shown poor communication among intensive care unit (ICU) nurses and doctors to be a common causal factor underlying critical incidents in intensive care. This study examines whether ICU doctors and nurses have a shared perception of interdisciplinary communication in the UK ICU.

METHODS

Cross-sectional survey of ICU nurses and doctors in four UK hospitals using a previously established measure of ICU interdisciplinary collaboration.

RESULTS

A sample of 48 doctors and 136 nurses (47% response rate) from four ICUs responded to the survey. Nurses and doctors were found to have differing perceptions of interdisciplinary communication, with nurses reporting lower levels of communication openness between nurses and doctors. Compared with senior doctors, trainee doctors also reported lower levels of communication openness between doctors. A regression path analysis revealed that communication openness among ICU team members predicted the degree to which individuals reported understanding their patient care goals ((adj)R(2) = 0.17). It also showed that perceptions of the quality of unit leadership predicted open communication.

CONCLUSIONS

Members of ICU teams have divergent perceptions of their communication with one another. Communication openness among team members is also associated with the degree to which they understand patient care goals. It is necessary to create an atmosphere where team members feel they can communicate openly without fear of reprisal or embarrassment.