Use of error management theory to quantify and characterize residents’ error recovery strategies

How Surgeons Think to Avoid Error: A Case Study of the Neurovascular Bundle Sparing During a Robotic Prostatectomy

OBJECTIVE

To illustrate how experts efficiently navigate a "slowing down moment" to obtain optimal surgical outcomes using the neurovascular bundle sparing during a robotic prostatectomy as a case study.

DESIGN

A series of semistructured interviews with four expert uro-oncologists were completed using a cognitive task analysis methodology. Cognitive task analysis, CTA, refers to the interview and extraction of a general body of knowledge. Each interview participant completed four 1 to 2-hour semistructured CTA interviews. The interview data were then deconstructed, coded, and analyzed using a grounded theory analysis to produce a CTA-grid for a robotic prostatectomy for each surgeon, with headings of: surgical steps, simplification maneuvers, visual cues, error/complication recognition, and error/complication management and avoidance.

SETTING

The study took place at an academic teaching hospital located in an urban center in Canada.

PARTICIPANTS

Four expert uro-oncologists participated in the study.

RESULTS

Visual cues, landmarks, common pitfalls, and technique were identified as the 4 key components of the decision-making happening during a slowing down moment in the neurovascular bundle sparing during a robotic prostatectomy.

CONCLUSION

The data obtained from the CTA is novel information identifying patterns and cues that expert surgeons use to inform their surgical decision-making and avoid errors. This decision-making knowledge of visual cues, landmarks, common pitfalls and techniques is also generalizable for other surgical subspecialties. Surgeon educators, surgical teaching programs and trainees looking to improve their decision-making skills could use these components to guide their educational strategies.

Formalizing the Hidden Curriculum of Performance Enhancing Errors

Despite its inevitability, error remains an uncomfortable topic for discussion amongst surgeons. There are a range of reasons cited for this; significantly, there is an inextricable link between a surgeon's actions and their patient's outcomes. Attempts to reflect on error are often unstructured and without a defined end point, and modern surgical curricula lack content to guide residents' learning on recognizing and reflecting on sentinel events. There is a need to develop a tool to guide a standardized, safe, and constructive response to error. The current educational paradigm revolves around error avoidance. However, there is an evolving evidence base surrounding the inclusion of error management theory (EMT) into surgical training. This method explores and incorporates positive discussions surrounding errors, and has been demonstrated to improve long-term skill acquisition and training outcomes. We must harness the performance enhancing effects of our errors in the same way we do our successes. Implicated in all surgical performance is human factors science/ergonomics (HFE) - the interface between psychology, engineering, and performance. Developing a national HFE curriculum in the context of EMT would provide a common language to facilitate objective reflections regarding surgeons' operative performance and manage the stigma associated with fallibility.

STOPS: A Coping Framework for Surgeons Who Experience Intraoperative Error

OBJECTIVE

To investigate the steps faculty surgeons take upon experiencing intraoperative error and synthesize these actions to offer a framework for coping with errors.

BACKGROUND

While intraoperative errors are inevitable, formal training in error recovery is insufficient and there are no established curricula that teach surgeons how to deal with the intraoperative error. This is problematic because insufficient error recovery is detrimental to both patient outcomes and surgeon psychological well-being.

METHODS

We conducted a thematic analysis. One-hour in-depth semistructured interviews were conducted with faculty surgeons from 3 hospitals. Surgeons described recent experiences with intraoperative error. Interviews were transcribed and coded. Analysis allowed for development of themes regarding responses to errors and coping strategies.

RESULTS

Twenty-seven surgeons (30% female) participated. Upon completion of the analysis, themes emerged in 3 distinct areas: (1) Exigency, or a need for training surgical learners how to cope with intraoperative errors, (2) Learning, or how faculty surgeons themselves learned to cope with intraoperative errors, and (3) Responses, or how surgeons now handle intraoperative errors. The latter category was organized into the STOPS framework: Intraoperative errors could produce STOPS: Stop, Talk to your Team, Obtain Help, Plan, Succeed.

CONCLUSIONS AND RELEVANCE

This study provides both novel insight into how surgeons cope with intraoperative errors and a framework that may be of great use to trainees and faculty alike.

Coping with errors in the operating room: Intraoperative strategies, postoperative strategies, and sex differences

BACKGROUND

Prior work has identified intraoperative and postoperative coping strategies among surgeons and has demonstrated surgical errors to have a significant impact on patient outcomes and physicians. Little research has considered which coping strategies are most common among surgeons and if there exist coping strategy differences among sex or training level.

METHODS

An electronic survey was distributed to surgical faculty and trainees at 3 institutions. Variables included coping techniques after making an error in the operating room. Participants were asked to report the effectiveness of their overall coping strategy.

RESULTS

A total of 168 participants (56% male, 45% faculty) experienced an operative error and answered questions regarding coping strategies. The only coping strategy significantly associated with positive ratings of coping effectiveness was, upon error, taking a step back and taking time to think and act (r = 0.17; P = .024). There were differences between men and women in both intra and postoperative coping strategies. Men (mean = 3.69/5, standard error = .09) viewed their overall coping strategy as more effective than women (mean = 3.38/5, standard error = .09), t(158.86) = 2.47; P = .015.

CONCLUSION

Although both male and female surgeons reported making errors in the operating room, differences exist in the strategies surgeons use to cope with these mistakes, and strategies differ in their ratings of effectiveness.

Formative feedback generation in a VR-based dental surgical skill training simulator

Fine motor skill is indispensable for a dentist. As in many other medical fields of study, the traditional surgical master-apprentice model is widely adopted in dental education. Recently, virtual reality (VR) simulators have been employed as supplementary components to the traditional skill-training curriculum, and numerous dental VR systems have been developed academically and commercially. However, the full promise of such systems has yet to be realized due to the lack of sufficient support for formative feedback. Without such a mechanism, evaluation still demands dedicated time of experts in scarce supply. To fill the gap of formative assessment using VR simulators in skill training in dentistry, we present a framework to objectively assess the surgical skill and generate formative feedback automatically. VR simulators enable collecting detailed data on relevant metrics throughout a procedure. Our approach to formative feedback is to correlate procedure metrics with the procedure outcome to identify the portions of a procedure that need to be improved. Specifically, for the errors in the outcome, the responsible portions of the procedure are identified by using the location of the error. Tutoring formative feedback is provided using the video modality. The effectiveness of the feedback system is evaluated with dental students using randomized controlled trials. The findings show the feedback mechanisms to be effective and to have the potential to be used as valuable supplemental training resources.