Improving Patient Safety by Identifying Latent Failures in Successful Operations

Department of Surgery, University of Oxford, London, UK.
Surgery (Impact Factor: 3.38). 08/2007; 142(1):102-10. DOI: 10.1016/j.surg.2007.01.033
Source: PubMed


The risk of technical failure during operations is recognized, but there is evidence that further improvements in safety depend on systems factors, in particular, effective team skills. The hypotheses that small problems can escalate to more serious situations and that effective teamwork can prevent the development of serious situations, were examined to develop a method to assess these skills and to provide evidence for improvements in training and systems.
Observations were made during 24 pediatric cardiac and 18 orthopedic operations. Operations were classified by accepted indicators of risk and the observations used to generate indicators of performance. Negative events were recorded and organized into 3 levels of clinical importance (minor problems, those negative events that were seemingly innocuous; intraoperative performance, the proportion of key operating tasks that were disrupted; and major problems, events that compromised directly the safety of the patient or the quality of the treatment). The ability of the team to work together safely was classified using a validated scale adapted from research in aviation. Operative duration was also recorded.
Both escalation and teamwork hypotheses were supported. Multiple linear regression suggests that for every 3 minor problems above the 9.9 expected per operation (P <.001), intraoperative performance reduces by 1% (P = .005), and operative duration increases by 10 minutes (P = .032). Effective teams have fewer minor problems per operation (P = .035) and consequently higher intraoperative performance and shorter operating times. Operative risk affected intraoperative performance (P = .004) and duration (P <.001), with the type of operation affecting only duration (P <.001). Eight major problems were observed; these showed a strong association with risk, intraoperative performance, teamwork, and the number of minor problems.
Structured observation of effective teamwork in the operating room can identify substantive deficiencies in the system, even in otherwise successful operations. Decreasing the number of minor problems can lead to a smoother, safer, and shorter operation. Effective teamwork can help decrease the number of small problems and prevent them from escalating to more serious situations. The most effective and sustainable route to improved safety is in capturing these minor problems and identifying related system improvements, combined with training in safe team working. This method is a validated and practical way to improve performance during otherwise successful operations.

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Available from: Ken R Catchpole,
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    • "Safer hospital systems are the key to achieving the Government' s overall goal of 'zero harm' in health care (Shappell and Wiegmann, 2001; Catchpole et al, 2007; Clover, 2013). To achieve the goal of safer systems, there must be a change in safety culture. "

    03/2015; 3(2):82-88. DOI:10.12968/jodp.2015.3.2.82
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    • "8 In order to achieve the full value of the checklist, it needs to be fully supported by all members of the surgical team. 9,10 Catchpole et al. (2007) showed that an accumulation of small errors in the operating room (OR) can escalate into more serious situations. 11 This group found a significant correlation between the quality of theatre team 'non-technical skills' and the number of technical errors which occurred. "
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    ABSTRACT: Background The importance of non-technical skills in improving surgical safety and performance is now well recognised. Better understanding is needed of the impact that non-technical skills of the multi-disciplinary theatre team have on intra-operative incidents in the operating room (OR) using structured theatre-based assessment. The interaction of non-technical skills that influence surgical safety of the OR team will be explored and made more transparent. Methods Between May–August 2013, a range of procedures in general and vascular surgery in the Royal Infirmary of Edinburgh were performed. Non-technical skills behavioural markers and associated intra-operative incidents were recorded using established behavioural marking systems (NOTSS, ANTS and SPLINTS). Adherence to the surgical safety checklist was also observed. Results A total of 51 procedures were observed, with 90 recorded incidents – 57 of which were considered avoidable. Poor situational awareness was a common area for surgeons and anaesthetists leading to most intra-operative incidents. Poor communication and teamwork across the whole OR team had a generally large impact on intra-operative incidents. Leadership was shown to be an essential set of skills for the surgeons as demonstrated by the high correlation of poor leadership with intra-operative incidents. Team-working and management skills appeared to be especially important for anaesthetists in the recovery from an intra-operative incident. Conclusion A significant number of avoidable incidents occur during operative procedures. These can all be linked to failures in non-technical skills. Better training of both individual and team in non-technical skills is needed in order to improve patient safety in the operating room.
    The surgeon: journal of the Royal Colleges of Surgeons of Edinburgh and Ireland 07/2014; DOI:10.1016/j.surge.2014.06.005 · 2.18 Impact Factor
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    • "This would allow for healthcare organisations to be compared and for deviations (in comparison with the norm) in particular types of complaint to be identified. The build-up of lower level complaint issues (eg, staff attitudes) within a unit or hospital might be better captured, and used as a potential (or ‘early-warning’) indicator of poor quality care, as shown with near miss data in the medical error literature.100 "
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    ABSTRACT: Background Patient complaints have been identified as a valuable resource for monitoring and improving patient safety. This article critically reviews the literature on patient complaints, and synthesises the research findings to develop a coding taxonomy for analysing patient complaints. Methods The PubMed, Science Direct and Medline databases were systematically investigated to identify patient complaint research studies. Publications were included if they reported primary quantitative data on the content of patient-initiated complaints. Data were extracted and synthesised on (1) basic study characteristics; (2) methodological details; and (3) the issues patients complained about. Results 59 studies, reporting 88 069 patient complaints, were included. Patient complaint coding methodologies varied considerably (eg, in attributing single or multiple causes to complaints). In total, 113 551 issues were found to underlie the patient complaints. These were analysed using 205 different analytical codes which when combined represented 29 subcategories of complaint issue. The most common issues complained about were ‘treatment’ (15.6%) and ‘communication’ (13.7%). To develop a patient complaint coding taxonomy, the subcategories were thematically grouped into seven categories, and then three conceptually distinct domains. The first domain related to complaints on the safety and quality of clinical care (representing 33.7% of complaint issues), the second to the management of healthcare organisations (35.1%) and the third to problems in healthcare staff–patient relationships (29.1%). Conclusions Rigorous analyses of patient complaints will help to identify problems in patient safety. To achieve this, it is necessary to standardise how patient complaints are analysed and interpreted. Through synthesising data from 59 patient complaint studies, we propose a coding taxonomy for supporting future research and practice in the analysis of patient complaint data.
    BMJ quality & safety 05/2014; 23(8). DOI:10.1136/bmjqs-2013-002437 · 3.99 Impact Factor
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