Dr Ken Catchpole Quality, Reliability, Safety and Teamwork Unit Nuffield Department of Surgical Sciences University of Oxford

A V-P shunt was being given to a paediatric patient. The scrub nurse was new to the operation, but was being supported by an experienced nurse, and the consultant surgeon was joined by a semi-retired colleague and mentor. The operation did not immediately proceed smoothly, with several problems and stoppages due to equipment problems; the diathermy did not immediately function effectively; the pneumatic hose on the cranial drill was occluded when it was secured to the drapes, and took several minutes to rectify (with the nursing staff first changing several parts of the drill before another nurse solved the problem). The surgeons were also struggling with the equipment, some of which was an inappropriate size for the patient, and since this operation was being performed in another part of the hospital from usual, no alternatives were available. To rinse the incision site for passing the V-P shunt under the skin, the semi-retired surgeon requested saline, but the inexperienced and overloaded scrub nurse, also attending to the needs of the consultant surgeon, accidentally gave the previously used syringe of local anaesthetic (chirocaine). As the surgeon was about to squirt the contents of the syringe onto the incision site, the second (experienced) scrub nurse realised the error and very loudly shouted “No don’t do that”, and the error was captured. Catchpole, Dale, Hirst, Smith, Giddings (2009). The Safer Theatre Teams Project: Final Report to the Health Foundation

STOP N N N Was the course useful? Positive course feedback Improved teamwork climate t = , p=0.007 Improved Teamwork Scores t = -2.36, p = 0.02 Reduced Technical Errors (t= p = 0.004) Reduced Procedural Errors (t=4.383, p<0.001) Were Outcomes Improved? Length of Stay Operating Time Complications Y Were attitudes changed? Y Was Behaviour Changed? Y Were working practices improved? Y N STOP 54 Team members received training 48 Operations studied pre-training 55 Operations post-training McCulloch, P, Mishra, A, Handa, A, Dale, T, Hirst, G, Catchpole, K. (2009). The effects of Aviation- style non-technical skills training on technical performance and outcome in the operating theatre. Quality and Safety in Healthcare.

Time out or Stop Check Pre 57%47%0%40% Post60%75%63%66% Briefing Pre 67%0% 24% Post71%100%14%58% Debriefing Pre 0% Post29%80%0%32% Site 1 Site 2 Site 3 All 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

YES....BUT....  Usually very well liked  Helps to bring safety into the open  Can encourage improvements in culture  Focused on individual responsibility / action  In some cases may lead to significant performance improvements  Of unregulated quality  Non-specific  Can be brittle / not sustainable  Limited in scope  Evidence of value limited  Cost / Benefit?

Displays & Controls Biomechanics Task Design Anthropometrics ‘Workspace’ Design Environmental stressors Cognition & memory Sensory perception Organisational processes

Healthcare practitioners have to perform to a high degree of precision in an environment that does not encourage the best human performance. Application of human factors knowledge will provide the organisations, environments, equipment, tasks and training that will encourage the best human performance.

Technology People Organisation Environment Tasks Carayon et al. Qual.Saf Health Care 2006, 15 Suppl 1:i50-i58. “HUMAN FACTORS”