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Dr Ken Catchpole Director of Surgical Safety and Human Factors Research Department of Surgery Cedars-Sinai Medical Center Los Angeles.

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Presentation on theme: "Dr Ken Catchpole Director of Surgical Safety and Human Factors Research Department of Surgery Cedars-Sinai Medical Center Los Angeles."— Presentation transcript:

1 Dr Ken Catchpole Director of Surgical Safety and Human Factors Research Department of Surgery Cedars-Sinai Medical Center Los Angeles

2  Introduce the concept of human factors  Explore what can go wrong in Cardiac and Vascular Surgery  Discuss how individual performance can be improved by shaping complex environments.

3 BANG!! Last Defense Secondary Defense Primary Defense  Humans:  are a fundamental component of ANY system  are uniquely able to function in uncertainty, and make trade-offs  create safety in complex systems  Complex systems:  are inherently unsafe  always function at the limits of capacity  require safety to be traded for other aspects of system performance.

4  Initiation of CPB without sufficient heparin is catastrophic (≈ 1 in 750)  Hospital A  Surgeon: Heparin please  Anaesthetist: Okay, heparin  Anaesthetist: Heparin going in  Surgeon: Are we ready to go on bypass?  Anaesthetist: Yes, ready  Perfusionist: Yes, I’m ready  Hospital B:  Surgeon: Okay?  Anaesthetist: Yes  Surgeon: Alright then “It’s fine if you know how we do it here.” “About 6 months ago we had a bit of an incident with someone new, but they weren’t here long.” Cons. Anaesthetist, March 2006 No recent heparin incidents Catchpole K (2011). Task, Team and Technology Integration in the Paediatric Cardiac Operating Room. Progress in Pediatric Cardiology 32 (2),

5 Vincent et al: Ann Surg 239(4):475, 2004 Outcome Patient Risk Factors + + Surgeon Factors = = “Once outcomes (usually mortality) have been correctly adjusted for patient risk factors, the remaining variance is assumed to be explained by individual surgical skill.”

6 Patient Risk Factors Surgeon Factors Surgical Flow Disruption Factors Technology Equipment design Maintenance Supervisory Training Staffing Scheduling Organizational Procedures Policies Resources + + Outcome = = Environment Distractions Interruptions Teamwork Communication Familiarity “Refinements in skill may be a relatively small element in the drive to reduce mortality from 10% to 1%. Optimizing the surgical environment, attention to ergonomics and equipment design, understanding the subtleties of decision making in a dynamic environment, enhancing communication and team performance may be more important than skill when reaching for truly high performance. ” Vincent et al: Ann Surg 239(4):475, 2004

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

8  13:39 P: Filtration stopped. AC: What’s the crit? P: 40. AC (to P): I think we ought to continue + discussion of new plan. Meanwhile, surgeon takes the MUF line out. 1A is involved in planning, but thinks the agreement is to concentrate the blood in the pump.  13:40 1A: got a gas? AC: reads out bloodgas  13:41 Surgeon asks for more calcium.  S: I took out the MUF line. P: We’ve started filtering again. S: I’m glad I said something. How much volume did you take out? P: Not a lot.  13:42 MUF line replaced. P: MUFfing again. S: Give 10. S: Give another 10.  13:43 P & AC make new filtering plan. New plan not clearly communicated Task conflict; attention elsewhere Early Mitigation New plan co-ordinated Fortuitous co-ordination Error goes unnoticed for >120s Catchpole K (2011). Task, Team and Technology Integration in the Paediatric Cardiac Operating Room. Progress in Pediatric Cardiology 32 (2),

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10 24 Operations 366 minor problems 29 different types Minor Problem Types PEDIATRIC CARDIAC SURGERY Catchpole, K, Giddings, A, De Leval, M, Peek, G, Godden, P, Utley, M, Gallivan, S, Hirst, G, Dale, T (2006). Identification of systems failures in successful paediatric cardiac surgery. Ergonomics 49(5-6), pp

11 416 minor problems 20 different types Minor Problem Types ORTHOPEDIC SURGERY Catchpole, K (2009). Observing Failures in Successful Orthopaedic Surgery. In L. Mitchell and R Flin (eds), Safer Surgery – Analysing Behaviour in the Operating Theatre. Aldershot: Ashgate. ISBN

12 Minor Problems Per Operation (Paediatric Cardiac Surgery) Catchpole et al. (2006). Identification of systems failures in successful paediatric cardiac surgery. Ergonomics 49(5-6).

13 Major Failures Minor Problems Per Operation (Paediatric Cardiac Surgery) Catchpole et al. (2006). Identification of systems failures in successful paediatric cardiac surgery. Ergonomics 49(5-6).

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15  Pediatric Cardiac  Swab causes compression of right coronary artery  Ex-sanguination during post-bypass heamofiltering  Omission of key surgical step  Premature separation from bypass due to breakdown in teamwork  Aortic homograft ruptured during sternotomy  Incorrectly labeled homograft  Difficult management of activated clotting time  Orthopaedics  Multiple uncertainty leads to teamwork breakdown, and less tibia.  Vascular  Saline given instead of heparin  Neuro  Mix-up between local anaesthetic and saline From approx 150 observed 8 sites [ Cardiac; Orthopaedic; 20+9 vascular; 6 Neuro; 9 Max Fax; 15?General; 1 Obs & Gyne ]

16 People prevent catastrophic failures Circumvent poor processes Capture Failures Make Trade- Offs Support each other Avoid problems Mitigate errors

17 Catchpole K (2011). Task, Team and Technology Integration in the Paediatric Cardiac Operating Room. Progress in Pediatric Cardiology 32 (2),

18 Catchpole, K (2009). Observing Failures in Successful Orthopaedic Surgery. In L. Mitchell and R Flin (eds), Safer Surgery – Analysing Behaviour in the Operating Theatre.

19 SURGICAL NOTECHS DimensionsElements Leadership & ManagementLeadership Maintenance of Standards Planning & Preparation Workload Management Authority & Assertiveness Teamwork & Co-operationTeam building & Maintaining Support of others Understanding team needs Conflict solving Problem Solving & Decision MakingDefinition & Diagnosis Option Generation Risk Assessment Outcome Review Situation AwarenessNotice Understand Think Ahead Below Standard (1)Basic Standard (2)Standard (3)Exceed(4) Behaviour directly compromises patient safety and effective teamwork. Behaviour in other conditions could directly compromise patient safety and effective teamwork. Behaviour maintains an effective level of patient safety and teamwork. Behaviour enhances patient safety and teamwork. A model for all other teams. Mishra, et al. (2009). The Oxford NOTECHS System: reliability and validity of a tool for measuring teamwork behaviour in the operating theatre. Quality and Safety in Healthcare, 18, pp

20 Catchpole et al. Improving patient safety by identifying latent failures in successful operations. Surgery 142(1), pp

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23 Menu Dial/Button On / Off Button

24 High Control Compatibility Low Control Compatibility

25 Technology People Organisation Environment Tasks Carayon et al. Qual.Saf Health Care 2006, 15 Suppl 1:i50-i58. “HUMAN FACTORS” Task standardization Roles & Rules Prediction & planing Selection Training Assessment Safety Culture Resilience Learning from Accidents Workspace Design Geographical distribution Physical Constraints Design Procurement Integration

26 Process Organisation –Task Allocation –Task sequence –Discipline and composure Teamwork –Leadership –Involvement –Briefing Threat and Error Management –Checklists –Predicting and Planning –Situation Awareness Technology Training Regimes

27 Multiple specialists Complex tasks Complex interfaces Time pressure Need for accuracy

28 Prior to Transfer Patient Transfer Sheet obtained from theatre Bedspace & equipment prepared in CCC Technology Transfer Equipment is configured in CCC SAFETY CHECK Information Handover Anaesthetist then Surgeon hand over information using Information Transfer Aide Memoir SAFETY CHECK Discussion & Plan Group discussion Anticipation of problems Immediate care strategy agreed Training time = 30 minutes

29  Teamwork  Fluidity  Role Definition  Training  Professional diversity  Recurrence  Expense  Tasks  Surgical complexity  Variation between surgeries  Variation between teams & surgeons  Technology  Piecemeal  Rarely replaced  Storage  Maintenance

30  People hold the system together  Behavior is not as much about ‘free will’ as it is about the influence of the system  Considering the mismatches between human and system can generate new ways to improve performance.  The way you make change is as important as what you change

31 Dr Ken Catchpole Director of Surgical Safety and Human Factors Research Cedars-Sinai Medical Centre Los Angeles

32  Catchpole K. (In Press). Spreading human factors expertise in healthcare: Untangling the knots in people and systems. BMJ Quality and Safety. Accepted 23 March  Catchpole K, Gangi A, Blocker R, Ley E, Blaha J, Gewertz B, Wiegmann D. (2013) Flow disruptions in trauma care handoffs. Accepted to the Journal of Surgical Research, Feb 19 th  Catchpole K, Wiegmann D (2012). Understanding safety and performance in the cardiac operating room: from ‘sharp end’ to ‘blunt end’. BMJ Quality and Safety 21(10),  Catchpole K (2011). Task, Team and Technology Integration in the Paediatric Cardiac Operating Room. Progress in Pediatric Cardiology 32 (2),  McCulloch, P, Rathbone, J, Catchpole, K, (2011). The effects of interventions to improve teamwork and communications amongst healthcare staff. British Journal of Surgery 98 pp  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 6(3),  McCulloch, P, Kreckler, S, New, S, Sheena, Y, Handa, A, Catchpole, K. (2010). Effect of a ‘Lean’ intervention to improve safety process and outcomes on a surgical ward. British Medical Journal. 341:c5469.  Catchpole, K, Bell, D, Johnson, S (2008). Safety in Anaesthesia: A study of reported incidents from the UK National Reporting and Learning System. Anaesthesia  Catchpole, K, Giddings, A, Wilkinson, M, Hirst, G, Dale, T, De Leval, M. (2007) Improving patient safety by identifying latent failures in successful operations. Surgery 142(1), pp  Catchpole, K, de Leval, M, McEwan, A, Pigott, N, Elliott, M, McQuillan, A, MacDonald, C, Goldman, A (2007). Patient Handover from Surgery to Intensive Care: Using Formula 1 and Aviation Models to Improve Safety and Quality. Pediatric Anesthesia 17(5),


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