Human factors - recognising and minimising errors in our day to day practice

The need for non-technical skills education in orthopedic surgery

BACKGROUND

The issue of surgical safety has increased significantly over the last few decades. Several studies have established that it is linked to non-technical performance, rather than clinical competencies. Non-technical skills can be blended with technical training in the surgical profession to improve surgeons' abilities and enhance patient care and procedural skills. The main goal of this study was to determine orthopedic surgeons' requirements of non-technical skills, and to identify the most pressing issues.

METHODS

We conducted a self-administered online questionnaire survey in this cross-sectional study. The questionnaire was piloted, validated, pretested, and clearly stated the study's purpose. After the pilot, minor wording and questions were clarified before starting the data collection. Orthopedic surgeons from the Middle East and Northern Africa were invited. The questionnaire was based on a five-point Likert scale, the data were analyzed categorically, and variables were summarized as descriptive statistics.

RESULTS

Of the 1713 orthopedic surgeons invited, 60% completed the survey (1033 out of 1713). The majority demonstrated a high likelihood of participating in such activities in the future (80.5%). More than half (53%) of them preferred non-technical skills courses to be part of major orthopedic conferences, rather than independent courses. Most (65%) chose them to be face-to-face. Although 97.2% agreed on the importance of these courses, only 27% had attended similar courses in the last three years. Patient safety, infection prevention and control, and communication skills were ranked at the top as topics to be addressed. Moreover, participants indicated they would most likely attend courses on infection prevention and control, patient safety and teamwork, and team management.

CONCLUSION

The results highlight the need for non-technical skills training in the region and the general preferences regarding modality and setting. These findings support the high demand from orthopedic surgeons' perspective to develop an educational program on non-technical skills.

Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety

Objective

To understand human factors (HF) contributing to disturbances during invasive cardiac procedures, including frequency and nature of distractions, and assessment of operator workload.

Methods

Single centre prospective observational evaluation of 194 cardiac procedures in three adult cardiac catheterisation laboratories over 6 weeks. A proforma including frequency, nature, magnitude and level of procedural risk at the time of each distraction/interruption was completed for each case. The primary operator completed a National Aeronautical and Space Administration (NASA) task load questionnaire rating mental/physical effort, level of frustration, time-urgency, and overall effort and performance.

Results

264 distractions occurred in 106 (55%) out of 194 procedures observed; 80% were not relevant to the case being undertaken; 14% were urgent including discussions of potential ST-elevation myocardial infarction requiring emergency angioplasty. In procedures where distractions were observed, frequency per case ranged from 1 to 16 (mean 2.5, SD ±2.2); 43 were documented during high-risk stages of the procedure. Operator rating of NASA task load parameters demonstrated higher levels of mental and physical workload and effort during cases in which distractions occurred.

Conclusions

In this first description of HF in adult cardiac catheter laboratories, we found that fewer than half of all procedures were completed without interruption/distraction. The majority were unnecessary and without relation to the case or list. We propose the introduction of a ‘sterile cockpit’ environment within catheter laboratories, as adapted from aviation and used in surgical operating theatres, to minimise non-emergent interruptions and disturbances, to improve operator conditions and overall patient safety.

Avoid, Trap, and Mitigate: Development of an Evidence-Based Crisis Management Framework in Surgery

BACKGROUND

Increasingly, surgeons are adopting broader roles in emergency response, on both clinical and executive levels. These have highlighted the need to develop healthcare-specific crisis management systems. Cross-professional research between safety-critical industries is a valuable method for learning crisis control. Commercial aviation, in particular, has been used to drive innovation in surgical safety. This study aimed to identify, adapt, and operationalize a surgical crisis management framework based on current practice in commercial aviation.

STUDY DESIGN

A multimethod qualitative study interrogated safety experts in commercial aviation and healthcare. Stage I used immersive observational fieldwork in commercial aviation practice. Stage II performed semi-structured interviews with senior airline pilots. "Snowball" sampling targeted professional networks, recruiting 17 pilots from 4 airlines. Thematic analysis was used to derive a model of crisis management. Stage III undertook 3 focus groups with 5 pilots and 5 healthcare safety specialists. Expert consensus methods were used to adapt the model to clinical practice.

RESULTS

Interview data provided 2,698 verbatim quotes on crisis management from aviation experts with a combined flying experience of 188,000 hours. Aviation crisis management was structured in 3 phases: avoid, trap, and mitigate. Adapted to clinical practice, these translated to crisis preparedness, recovery, and containment interventions. Additionally, the study identified 7 types of implementation tools and 9 crisis management skills that could be used to operationalize this framework in surgical practice.

CONCLUSIONS

Surgical crisis management can follow the avoid, trap, and mitigate framework used in commercial aviation. Implementation relies on the combined use of crisis skills and performance tools. Crisis management should be delivered as part of a systems-based approach that relies on well-integrated failure management models. Simulation and in-situ validation of this framework is needed.

Pilot study to evaluate safety culture perception in the operating theatres of an acute NHS Trust using the National Air Traffic Services (NATS) App

An area critical to safety in an organisation is the perceived and actual culture. National Air Traffic Services (NATS) work closely with large safety-critical industries including various aviation companies to enable them to identify strengths and vulnerabilities with the aim of improving safe practice. NATS have developed a simple free downloadable self-assessment App that individuals can use to assess their own culture perception in their organisation. The App has 16 questions arranged in four domains but to our knowledge it has not been used to date in healthcare. As part of the initiatives to improve staff culture, we evaluated operating theatre colleagues' safety perception in our large acute NHS Trust in a pilot study using the NATS safety App. Staff downloaded the App to their smart device before completing it. Responses were sent anonymously through the App and collated by NATS. A total of 146 colleagues downloaded and completed the questionnaire. One hundred and seventeen staff (80%) felt encouraged to report safety concerns, but 86% (n=126) confirmed a lack of available support from healthcare managers. Only 43% of respondents (n=63) would find it easy to challenge colleagues if they observed unsafe behaviour. This pilot study has identified positive indicators of an evolving NHS safety culture, and some concerns about speaking up, support, and challenging colleagues without fear. These issues are known to occur across healthcare. Further work is needed in the NHS to provide a supportive environment to improve patient safety, and lower hierarchy in surgical teams.

Medical error reporting among doctors and nurses in a Nigerian hospital: A cross-sectional survey

AIM

To compare doctors' and nurses' perceptions of factors influencing medical error reporting.

BACKGROUND

In Nigeria, there is limited information on determinants of error reporting and systems.

METHODS

From the total workforce (N = 600), 140 nurses and 90 doctors were selected by random sampling and completed the questionnaire February to March 2017.

RESULTS

All 140 nurses and 90 doctors approached responded. Inter-professional differences in response to sentinel events showed that 55/140, 39.3% nurses and 48/90, 53.3% doctors would never report wrong medicines administered and 49/138, 35.5% nurses and 35/90, 38.9% doctors would never report a haemolytic transfusion error. Some respondents (72/140, 51.4% nurses vs. 29/90, 32.2% doctors) were unaware of reporting systems. Most (77/140, 55% nurses vs. 48/90, 53.3% doctors) considered these to be ineffective and confounded by a 'blame culture'. Perceived barriers included lack of confidentiality; facilitators included clear guidelines about protection from litigation.

CONCLUSIONS

Error reporting is suboptimal. Nurses and doctors have a minimal common understanding of barriers to error reporting and demonstrate inconsistent practice.

IMPLICATIONS FOR NURSING MANAGEMENT

Suboptimal reporting of serious adverse events has implications for patient safety. Managers need to prioritize education in adverse events, clarify reporting procedures and divest the organisation of a 'blame culture'.

Follow-up after oral cancer treatment-Transition to a personalized approach

BACKGROUND

Guidelines for follow-up after oral cancer treatment are not site-specific and encompass the entire head and neck area rather than the oral cavity alone. This one-size-fits-all protocol disregards the differences in aetiology, treatment and differential distribution of new disease between the subsites. With the effectiveness of follow-up in early detection of new disease being put into question, the focus of follow-up programmes might shift to other aspects of survivorship care. Personalization of follow-up is important, considering patient-specific features and needs. Furthermore, the COVID-19 pandemic urges us to rethink our follow-up practice.

FINDINGS

This paper discusses ways in which routine follow-up in patients treated for oral cancer can be optimized. Patients with a high risk of new disease might benefit from an intensified follow-up regimen, whilst patients with a low risk of new disease, a low chance of cure or limited life expectancy could benefit from a de-intensified follow-up regimen. The latter could include a shorter follow-up period and focus on goals other than early detection of new disease. Education of patients to report new symptoms early is of vital importance as the majority of new disease presents symptomatically. Other health care professionals such as specialist nurses and dentists need to play an important leading role in survivorship care. Remote consultations may be useful to perform more efficient and patient-centred follow-up care.

CONCLUSION

Routine follow-up needs to be seen as an integrated part of an individualized survivorship plan that is provided by the entire multidisciplinary team.

Night shift work in resident physicians: does it affect mood states and cognitive levels?

BACKGROUND

The effects of night shift work on health status have been widely studied. Night workers seem to smoke more, eat badly and show a low propensity to physical activity. Night work can be associated with an increase in cardiovascular and gastrointestinal disorders, alterations in immune response, diabetes, aging, hormonal imbalance, and premature death; alteration of circadian rhythm is also regarded as a risk factor for breast cancer and neuropsychiatric disorders. Moreover, several studies have highlighted the effects of sleep deprivation on clinical performance, quality of care and personal safety of healthcare personnel. No studies have investigated the effects of night work on Italian resident physicians and compared its effect across specialties. This study aims to assess the prevalence of sleep disorders, possible cognitive impairment and mood states, in relation to night shift work among resident physicians.

METHODS

80 resident physicians, attending the postgraduate training into an Hospital located in the South of Italy, were divided into 4 areas (medical, surgical, services and anaesthesia). They were recruited from July 2017 to June 2018 and participated to a survey consisting of 4 questionnaires to investigate the presence of sleep deprivation and sleep quality (Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index), their cognitive status (Mini Mental State examination) and mood profiles (Profile of Mood States, POMS). Analysis of variance was used for comparison of questionnaires scores across specialties.

RESULTS

Authors reported no sleep deprivation, no sleep disorders and their outcomes, no changes in intellectual efficiency and no cognitive impairment in this population, neither in the areas performing night shifts nor in those involving only day shifts. Mood states measured by POMS showed a borderline level of Anger-Hostility (A) value among the residents of the medical area and services, and an increase slightly beyond the physiological levels of the T-score 50 of Fatigue-Inertia (F) always in the same groups. An increase in the Vigour-Activity (V) value beyond T-score 50 levels was also observed among residents of all the areas considered.

CONCLUSIONS

Emotional involvement could be attributed to the gap between high professional demand and lack of experience and knowledge among trainees. Tutors should help their students in order to identify earlier changes in the mood. Improvement in the organization of the trainee's activity could reduce the emotional overload.

A literature review exploring common factors contributing to Never Events in surgery

This literature review explores some common factors contributing to Never Events in surgery. Despite significant patient safety efforts, serious preventable surgical events that turn into Never Events continue to exist. Various search databases were used to collect relevant contemporary data within the time parameters 2008-2019. The literature revealed numerous studies from the United States of America and worldwide, and the need for more current research from the United Kingdom on the subject. The key findings emphasise that communication failure, situational awareness, fatigue, lack of healthcare professionals and surgical caseload are common contributing factors to Never Events. The implications of these findings for practice highlight that despite multidisciplinary approaches, technologies, policies and strategies, Never Events are a common phenomenon in surgery. To minimise their occurrence, more robust and reliable safety management systems need to be in place within healthcare organisations. In depth understanding of cognitive Human Factors and non-technical skills need to be encouraged through education, training and continuous evaluation of success and failure.

Factors affecting the complexity of dental implant restoration - what is the current evidence and guidance?

Objectives The aim of this paper is to identify the factors that affect the complexity of implant restoration and to explore the indices that help us to assess it. With this knowledge the growing number of clinicians restoring dental implants will have a better understanding of the available guidance and evidence base, and the differing levels of competence required.Study design A literature review was conducted. The selection of publications reporting on complexity was based on predetermined criteria and was agreed upon by the authors. After title and abstract screening 17 articles were reviewed. The articles that were utilised to form the ITI SAC tool and Cologne Risk Assessment we also included.Assessing complexity Two key guides are available: International Team for Implantology's Straight-forward Advanced Complex tool and the Cologne ABC risk score. While these guides help identify treatment complexity they do not provide a strong enough evidence base from which to solely base clinical decisions. The key patient factors are expectation, communication, the oral environment, aesthetic outcome, occlusion, soft tissue profile and the intra-arch distance, whereas the key technical factors are impression taking, type of retention, loading protocol and the need for provisional restorations. Human factors also have a significant effect on complexity, specifically, the experience and training of the clinician, team communication and the work environment.Conclusions There are many interconnecting factors that affect the complexity of dental implant restoration. Furthermore the two widely used indices for the assessment of complexity have been investigated, and although these offer a good guideline as to the level of complexity, there is a lack evidence to support their use. The development of evidence-based treatment and protocols is necessary to develop the current indices further, and these need to be expanded to include other critical areas, such as human factors. A practical guide to aid practitioners in reducing complexity has been proposed.