Safer Surgery part 38 pptx

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it to be labelled a PM situation, there would not be an additional reminder
about the intention.
The execution action, putting the intention into practice, is considered a
separate phase in the model. It can contain specic errors, e.g., related
to the ability to perform the intended task or meta-cognitive abilities to
monitor the success of the intention implementation.
Finally, the acting person must note whether or not the intention was fullled
and, if yes, also to what extent. On occasion, intentions are only partially
fullled but seem to the acting person as though the task has already been
completed.
Depending on the phase of the cycle in which this disturbance occurs,
different error types would be responsible for the failed execution of the
intention as error form. Future research should aim to better understand
the error types. We will use the framework introduced here to more
closely analyse the examples presented at the start of the chapter. This
will necessarily involve some assumptions and even speculations – as PM
failures are related to intentions, which can not be observed directly.
Analysis of the Clinical Examples within the PM Framework
Example 1 – Treatment in Time
The situation where the anaesthesia team must remember the antibiotic can be
classied as an event-based PM task. This case is particularly difcult because
the intention should be fullled before another event (skin cut) takes place.
Therefore, the anaesthesia crew would need to create some kind of cue that
could help them remember to provide the antibiotic before the skin cut. The skin
cut is not an appropriate cue to trigger the action, as it occurs too late. The newly
created cue could be ‘internal’: the crew could try to anticipate in detail the
moment in which they want to remember to administer the drug. They could thus
make their internal intention stronger, so that they would be more alert about the
beginning of the window of opportunity (Gollwitzer and Schaal 1998, Schweiger

Gallo and Gollwitzer 2007). Another strategy which is more ‘external’ and is
already partially implemented according to the task description. The team can
create some kind of external reminder (here the bottle that is taped to the chart).
They could also use a combination of internal and external strategies when trying
to remember to execute the intention: they could anticipate the moment in which
they take the bottle off the chart and try to use this act as a cue to perform the
intention of administering the drug as well. Potentially, it might be easy to forget
to actually administer the drug if the bottle is taken away from the chart but not
used immediately. Just handling the bottle carries the risk of psychologically
‘nishing’ the task (pars-pro-toto error type).
4.
5.
6.
Remembering To Do Things Later and Resuming Interrupted Tasks
345
Example 2 – Recurrent Measurements
As opposed to the rst example, the intention in this example (anaesthetist
checking blood glucose) needs to be remembered by a single person, not a team.
This has advantages and disadvantages. Research shows that asking other people
to help remember might, at times, not be effective. One underlying mechanism
might be the shared responsibility for forming and retaining the intention leads
to lowered cognitive energy for all involved (Shaefer and Laing 2000). This
example further involves a recurring time-based intention: the blood glucose
needs to be checked at regular intervals. The anaesthetist relies on the alarm
clock which acts as an external reminder. However, the effectiveness of this
reminder might be compromised by the concurrent tasks during the operation
– which might be even more obviously demanding (the negative effects of low
blood glucose are not immediately obvious in anaesthetized patients). So, when
the timer clock goes off and the anaesthetist is just performing another task, a
new PM challenge is posed – the intended action is again interrupted or cannot

even be started. The reminder does not have a memory for the execution of
the task in the sense of the PM Phase 5, described above. Using such external
reminders might have the drawback that their potential to help might not be
usable in a specic moment and, in addition, using them requires resources in
itself, thus adding to the complexity of the situation.
Example 3 – Dynamic Change of Plans
Unlike the rst two examples, Example 3 (remembering to perform an
appendectomy) involves changes of plans during the actions – a common situation
in medicine as a dynamic eld. During the demanding operation, the decision is
made dynamically to extend the treatment by including an additional treatment after
the originally planned steps are fullled. This situation requires either modication
of the original intention or the formation of a new intention – a differentiation that
might be difcult to make in practice but could be relevant for the strengths of the
intention and thus the likelihood of the execution of this activity-based intention.
In either case, due to the demanding operation, the forming of the intention might
be weak and with little energy, increasing the likelihood of ‘forgetting’ it. In
addition, this situation is error prone because of its ‘pars-pro-toto’ character (cf.
(Dieckmann et al. 2006). When the originally planned part of the operation is
nished, the fth phase of the PM cycle becomes very relevant: the evaluation
of the results. As the original intention is fullled completely, it might be easy to
mistakenly see the whole, now enlarged intention as fullled, thus missing the
newly formed part. Fullling a part of the intentions might feel as if they were
being fullled completely.
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Results from a Pilot Study
After the theoretical considerations during the analyses of the examples, we report
empirical data from a pilot study about PM in acute care settings; it was meant as
a rst approximation to PM in acute medical care – a so far neglected connection
(Dieckmann et al. 2006).

Simulator Study
In one study we used a patient simulator to investigate situations prone to PM
failures and the effects of the missed execution of intentions (Dieckmann et
al. 2006). In summary, we created ten different simulation scenarios for acute
care settings. Each scenario contained between one and three PM situations,
which differed in how closely they were related to the context of the scenario.
The match to the context was the rst independent variable. Participants were
medical students who were close to or within their nal year, and worked through
the scenarios in pairs. The dependent variable was whether the team (i.e., one
or both members) executed the intentions during the scenario. After each
scenario, each student rated the importance of the intention and several other
elements of the scenario. We used this rating as a second independent variable.
We analysed the number and percentage of executed tasks in dependency of
type and importance. No signicant differences were found with regard to
either factor. Subjectively, important tasks tended to be executed more often
than unimportant tasks and the closer the task matched the overall goal of the
situation (learning), the more often it tended to be executed. Despite the lack of
signicant results, since it was possible to trigger PM errors in these scenarios,
we believe that the simulator is an appropriate research setting for studies on
prospective memory.
Questionnaire Study
In another part of the study, we assessed the attitudes and experiences of elements
of prospective memory in anaesthetists and intensive care physicians from diverse
healthcare institutions in Germany. Based on the results of a workshop with
eight anaesthetists of different experience levels, we developed a questionnaire,
which described 24 PM-prone situations. The questionnaire briey explained
the concept of PM. Respondents rated the relevance of PM for their practice and
estimated how often they had encountered each situation during the preceding
month (see Table 20.1, mean count) and how often they failed to execute the
specied intention. We computed percentages from these counts for every

participant and averaged these percentages across situations (Table 20.1, mean
percentage). Questionnaires were sent to 680 anaesthesiologists and intensive
care physicians in German healthcare institutions of different sizes and types
(university hospitals, community hospitals, private practice) from all 16 federal
Remembering To Do Things Later and Resuming Interrupted Tasks
347
states in Germany. We sent every institution a letter that described the study,
accompanied by the appropriate number of blank questionnaires and stamped
return envelopes for the relevant staff.
There were 112 questionnaires returned (16.4 percent response rate). The mean
duration of job experience of the respondents was 10 ± 8 years. A total of 69 percent
of respondents rated the inuence of PM failures on the development of critical
incidents as ‘very big’, ‘big’ or ‘somewhat big’ (mean and standard deviation:
4.03 ± 1.01; n=107), while 59 percent estimated the threat of such failures to
patient safety as ‘somewhat big’ or greater (3.78 ± .98; n=107). ‘No impact at all’
was not checked by any of the respondents. Table 20.1 shows the experiences of
situations prone to failure of PM and the respondents’ estimate of how often they
are connected with missed executions of the intention.
Situation
Mean
count ± SD
experienced
Mean
% ± SD
forgotten
Number
of valid
estimations (n)
A medical intervention is
interrupted by a more important

task and you want to correctly
resume the interrupted treatment
36.3 ± 41.7
11.3 ± 9.0 98
You need to check whether
another person executed the
intention
28.9 ± 43.8 16.0 ± 17.0 61
You are disturbed by another
person while you are about to
execute an intention
25.7 ± 58.8 18.8 ± 19.5 83
You are disturbed by an alarm
while you are about to execute an
intention
24.7 ± 66.9 11.6 ± 14.6 78
You are not certain whether you
already executed the intention or
not
15.1 ± 36.6 15.5 ± 20.4 100
The intention concerns an action
that is unimportant for you
10.5 ± 15.4 40.9 ± 29.7 82
You need to postpone a routine
action and perform it later
10.2 ± 14.5 16.4 ± 19.4 81
You executed a very similar but
not the intended action
9.3 ± 18.2 15.4 ± 20.0 86
Table 20.1 Selected estimations of frequency of prospective memory

based situations in medicine (mean count), error proneness of
situations (mean %), and valid number of estimations for each
situation (n)
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348
Because of the low response rate and an unrepresentative sampling,
generalizations need to be drawn carefully from this questionnaire. Nevertheless,
we think the results can generate hypotheses and emphasize the need for more
research in this regard. One of the formed hypotheses is that interruptions
appear to impact PM in different ways. Interruptions by persons are estimated
to be more disruptive than those by alarms. This difference might be due to the
fact that interruptions by other people tend to be stronger than those by alarms.
Where it is possible to take a short time to nish a thought, task or part of a
task when the alarm goes off, this is often more difcult with interruptions by
other persons. Observations in the intensive care setting support this assumption:
interruptions by other persons were followed by immediate reactions by those
who were interrupted. These results t also with the tendency for face-to-face
communication in medical settings, described above. It is a question of further
research to discover the underlying error types for this phenomenon.
Discussion of Research Related to Prospective Memory and its Failures in
Acute Care Settings
There is a large body of basic psychological research on prospective memory,
relying to a large extent on highly controlled studies in laboratories. While this type
of research allows for looking more closely at the different error types underlying
the missed execution of intentions, it seems difcult at times to use the results
from those studies to improve patient care because it is difcult to directly apply
the results from articial research situations. The discussions showed that the
theoretical PM framework is helpful to have a closer look at PM and how it relates
to patient safety. However, there are challenges when trying to strictly apply the
denitions within the PM framework to the dynamic settings of eld research in

Situation
Mean
count ± SD
experienced
Mean
% ± SD
forgotten
Number
of valid
estimations (n)
Y
ou know that you wanted to do
something but cannot remember
what it was
8.8 ± 11.4 36.2 ± 31.7 88
The intention concerns an action
that is unpleasant for you
7.7 ± 9.0 8.1 ± 16.7 82
Problems using a device cause
delays in executing an intention
6.9 ± 12.1 18.4 ± 20.8 91
You need to postpone an
exceptional task and do it later
7.2 ± 11.6 16.0 ± 19.9 82
Table 20.1 Concluded
Remembering To Do Things Later and Resuming Interrupted Tasks
349
the acute care settings. Intentions, as inner processes, are not directly observable
but need to be inferred. In addition, they are not always conscious in all parts. It
seems necessary to also conduct more applied studies under more ecologically

valid conditions and to progress the knowledge by looking at prospective memory
from both the applied and the basic science perspective.
As with all studies of errors, it is also a challenge in PM research, to dene
the ‘unit of analysis’, i.e., what is to be considered an error and what is correct
performance (Wehner et al. forthcoming). In most PM studies, ours included, the
investigation relies on the assumption that participants form an intention from
instructions. If the instruction is never transformed into an intention, it would be
wrong to assume an error, if no related task is executed. For this reason, we think
it is benecial to have a closer look at interruptions. It seems reasonable that tasks
which are not yet completed are related to the intention of resuming and nishing
it. In some cases there might also be the conscious decision not to pursue the
intention any more, so that supplementary interviews and other data would still be
helpful. In this regard, we acknowledge the smart methodological aspects of the
rst group studying PM-related issues in the 1920s around Kurt Lewin (Birenbaum
1930, Ovsiankina 1928, Lewin 1926, Zeigarnik 1927), who investigated, using
interviews, how easily participants could remember intentions that were fullled
as opposed to those that were not fullled.
Another challenge for research in PM and its failures stem from the fact that,
in many cases, the window of opportunity is articially strictly dened under
study conditions, possibly decreasing the ecological validity of the results. In
many clinical situations, the borders of the window of opportunity are not dened
sharply, but more in terms of transitions (see Example 2 above). In many (certainly
not all) cases it is not of signicance whether a certain task is fullled in a specic
time frame. The sequence of events might be more important in many cases (e.g.,
Example 1) than the absolute time and in some cases there might be discussions
about the existence of a window of opportunity in the rst place (i.e., in those
cases where it is difcult to dene the gold standard of medical practice).
There is much debate about the memory component of PM. As discussed
above, the phenomenon of executing or not executing a certain intention involves
many different processes during the phases of a PM cycle. In order to understand

the underlying error mechanisms (error types), we would need a very ne-grained
analysis – which is often not possible in applied studies. In this regard it might
be better to (a) talk about intentions and their execution instead of PM in applied
settings and (b) to integrate basic, laboratory-based research with more applied
studies, with the aim of validating the ndings.
Implications for Clinical Practice
For dealing with each threat to patient safety, it is important to work through
at least three steps. The rst step involves the removal of the threat from the
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350
system, reducing the number of PM-prone situations. One could analyse and
optimize communication and interaction patterns, potentially decreasing the
number of interruptions and the amount of time spent waiting for team members.
This would be a question of work system design. In a second step, which should
only be taken if the rst step is not possible, one could try to build in safety
measurements, to prevent errors in PM-prone situations. This can be external
reminder systems, checklists and other (technical) devices that might help in
optimizing PM performance. Thirdly, and this step should only be taken if the
rst two steps have failed, one could train people to handle the remaining PM
situations better. The priority should be to systematically design weak points
out of the system instead of training people to handle them. Such training could
involve strategies that can help remembering and also showing the sometimes
counter-intuitive effects of some of those strategies (e.g., asking someone to
help remember, which might decrease the likelihood of executing the intention
as discussed above). Here we do need deeper analyses, trying to understand
how people redene tasks into primary, secondary, etc. and decide what is the
disturbance and what is the disturbed element.
Work system design can tailor the interplay of humans, technology and
organization in a PM friendly and PM error friendly way (Wehner 1992, von
Weizsäcker and von Weizsäcker 1984). Depending on the perspective of this

interplay and the underlying error types, we need different ways for improvement.
Those ways would necessarily involve cognitive, but also social and organizational,
elements.
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Chapter 21
Surgical Decision-Making: A Multimodal
Approach
Nick Sevdalis, Rosamond Jacklin and Charles Vincent
Introduction
Surgeons, in conjunction with their patients and colleagues, have to make risky
and irreversible choices. The ability to make clinical decisions, both within and
outside the operating theatre, is a key feature of surgical expertise, which has
been highlighted in attempts to dene the essential competencies of a surgeon. For
example, the CanMEDS model of clinical competency (Frank and Langer 2003),
asserts that ‘the role of medical expert/clinical decision-maker is central’ (Frank
et al. 1996, p. 4), and includes elements such as diagnostic reasoning, clinical
judgement and clinical decision-making (Frank 2005). The CanMEDS model was
inuential in the development of the Intercollegiate Surgical Curriculum Project,
which forms the framework for the postgraduate training of surgeons in the UK
(Canter and Kelly 2007).
This chapter discusses surgical decision-making in both a clinical and research
context and introduces a multimodal approach to measuring and assessing surgical
decision-making. In what follows, we begin by outlining the role of decision-
making within the ‘systems approach’ to surgical safety. Next, we describe some
important features of surgical decision-making in its clinical context. Thirdly, we
provide a brief overview of some of the methods available for studying surgical
decision-making. Fourthly, we introduce the multimodal approach that we have
taken to investigate, measure and train surgical decision-making in our research
group and the results we have achieved so far. We conclude with a discussion of
different research approaches, including limitations and implications for research
in and assessment of surgical decision-making.

(i) The ‘Systems Approach’ to Surgical Safety
In recent years, there have been shifts in the understanding of surgical performance
and surgical outcomes. Traditionally, surgical performance and outcomes were
understood as a function of the patient’s risk factors (i.e., the severity of the
disease and existing co-morbidities). In the past ten years or so, with the surge
in the use of surgical simulators and the associated development of the evidence