Safer Surgery part 3 doc

Safer Surgery
xx
Helen Purdie is a senior research sister at the Clinical Research Facility in
Shefeld. She has also gained surgical experience as a surgical care practitioner
(SCP) within the specialties of cardiac and vascular.
Marcus Rall is an anaesthetist and the director of the Centre for Patient Safety and
Simulation (TüPASS) at the University of Tuebingen, Germany. Marcus is leading
the two incident reporting systems and PaSOS.
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Silke Reddersen is anaesthetist at Tuebingen University Hospital, Germany. She
works for the Tuebingen Centre for Patient Safety and Simulation with an emphasis
on in-situ trainings, instructor training and the German Incident Reporting systems
PaSIS and PaSOS.
Glenn Regehr is Richard and Elizabeth Currie Chair in Health Professions
Education Research, Professor and Senior Scientist at the Wilson Centre for
Research in Education, University Health Network and University of Toronto.

David Rowley is an orthopaedic surgeon. He is Director of Education at the Royal
College of Surgeons of Edinburgh as well as Visiting Professor of Surgery at
Edinburgh University, and Emeritus Professor at Dundee University. d.i.rowley@
dundee.ac.uk
Nick Sevdalis is an experimental psychologist. Initially a post-doctoral researcher
in the Imperial Department of Surgery (2004–2006), Nick was appointed Lecturer
in Patient Safety (2006 to the present) – with two years spent jointly in Imperial
and the National Patient Safety Agency (2006–2008). Nick investigates non-
technical skills/teamwork in surgery.
J. Bryan Sexton is a psychologist by training and is the Director of Safety Culture
Research and Practice at the Johns Hopkins Quality and Safety Research Group.
He has collected culture data in over 2000 hospitals, in 15 countries.
Andrew Smith is a consultant anaesthetist at the Royal Lancaster Inrmary and
Honorary Professor of Clinical Anaesthesia at Lancaster University, UK. He has

a strong interest in risk, safety and professional expertise in anaesthesia. andrew.

Arnd Timmermann is consultant anaesthetist and co-director of the Centre for
Education and Simulation in Anaesthesiology, Emergency and Intensive Care
Medicine at University Medical Centre Göttingen (Germany). atimmer@med.
uni-goettingen.de
Notes on Contributors
xxi
Eric Thomas is a professor of medicine at the University of Texas – Houston
Medical School and Director of the UT-Houston Memorial Hermann Center
for Healthcare Quality and Safety. He studies several aspects of patient safety
including diagnostic errors, teamwork and safety culture.
edu
Paul Uhlig is a cardiothoracic surgeon and associate professor in the Department
of Preventive Medicine and Public Health at the University of Kansas, School
of Medicine – Wichita in Wichita, Kansas. His area of special expertise is social
architecture in healthcare and methods for transformation of healthcare practice
culture.
Shabnam Undre is a doctor of medicine and is a trainee in urology. She recently
completed her PhD, ‘Teamwork in the Operating Theatre’, at Imperial College and
is involved in various research projects for assessing and improving teamwork in
surgery.
Charles Vincent trained as a clinical psychologist and has conducted research on
risk management, medical error and patient safety in a number of settings. He is
currently Director of the Centre for Patient Safety and Service Quality at Imperial
College Academic Health Sciences Centre.
Bart Vrouenraets is a surgeon working at the Department of Surgery at Sint
Lucas Andreas Hospital in Amsterdam. His specialities are surgical oncology and
general surgery.
Johannes Wacker is a board-certied specialist in anaesthesiology FMH and is

working as a consultant anaesthetist at the Department of Anaesthesia, University
Hospital Zurich, Zurich, Switzerland. ; http://www.
anaesthesie.usz.ch
Carl-Johan Wallin is senior consultant in anaesthesia and intensive care
medicine, Diplomate of the European Academy of Anaesthesiology (DEAA)
and PhD in medical sciences. He is Director of Training at the Department of
Anaesthesiology and Intensive Care at Karolinska University Hospital Huddinge,
and the manager of the Division of Advanced Patient Simulation, Centre for
Advanced Medical Simulation at Karolinska in Stockholm, Sweden. carl-johan.

Linda Wauben is an engineer working on her PhD in a collaborative project with
the Erasmus MC and Delft University of Technology focusing on human factors.

Safer Surgery
xxii
Theo Wehner is a professor and holds the Chair of Work and Organizational
Psychology at the ETH Zurich’s Department of Management, Technology
and Economics. He specializes in human error, experiences and knowledge
management.
Sarah Whyte worked for ve years as a research coordinator in the operating
room. She is currently a doctoral candidate in English Language and Literature at
the University of Waterloo and a doctoral fellow at the Wilson Centre in Toronto,
Canada.
Yan Xiao is associate professor of anaesthesiology and director for research in
patient safety at University of Maryland. He authored over 60 journal articles in the
areas of patient safety including coordination, team performance, and technology
enhanced performance.
George Youngson is professor of paediatric surgery at Royal Aberdeen Children’s
Hospital. His other interests are surgical education and advising government on
healthcare strategy. He is chairman of the Patient Safety Board at the Royal College

of Surgeons of Edinburgh.
Steven Yule is a lecturer in psychology at the University of Aberdeen with
background training in human factors. His research is on psychological aspects
of behaviour and safety in high-risk organizations, especially leadership and non-
technical skills in surgery. www.abdn.ac.uk/~psy296/dept
Enikö Zala-Mezö is work and organizational psychologist, lecturer and researcher at
Zurich University of Applied Sciences, Zurich, Switzerland.
Foreword
Charles Vincent
What could a background in psychology, medical error and safety bring to surgery
and what would surgeons, anaesthetists and nurses make of patient safety? These
were the questions that faced me when I moved, in 2002, from a department of
psychology to a department of surgery. Initially I read the surgical literature to see
how safety was approached. The journals were full of descriptions of the complex
technicalities of operative procedure and of the inuence of co-morbidities
and risk factors on patient outcome. From the safety point of view, there was
pioneering work on human factors and crisis training in anaesthesia and some
impressive work on surgical skills. However, very little had been written on topics
that would appear fundamental to safe surgery such as the nature of error and
systems, teamwork, decision-making, the working environment, culture and all
the other staples of the safety world. It was puzzling, and rather worrying, that the
safety point of view and the surgical literature seemed so divergent.
Even more puzzling however was that the surgical literature did not seem to
accord with the daily experience of clinicians. My colleagues were generous in
explaining the challenges of their work; I watched and listened. Technical issues,
risk factors and so on were certainly critical. However, their stories of the operating
theatre revolved around difcult decisions, equipment problems, teams that just
failed to gel, the difculty of bringing a team together during a crisis, the way the
wider hospital impacted on the operating theatre and so on … in fact a litany of
classic safety issues. None of this appeared to be reected in the surgical journals

or in surgical research.
The chapters in this book mark the huge progress that has been made over
the last ve years in broadening the scope of research on the factors that create
safety in the operating theatre and beyond. The issues that nurses, anaesthetists
and surgeons have always dealt with, talked about and suffered are now regarded
as worthy of serious study and recognized as being critical to safe care. The
chapters are, both individually and collectively, extraordinarily rich and it would
be pointless to anticipate the detailed arguments in a foreword. However, it is
perhaps worth reecting on some of the major themes of these studies which, to
my mind, underpin the progress that has been made.
First, it is worth recalling that studies of clinical work, particularly on error and
safety, can arouse considerable suspicion and even hostility between clinicians
and researchers. In contrast, as the Edinburgh meeting made clear, these research
teams are grounded in trust, mutual respect and the desire to work together for safer
healthcare. This collaborative and optimistic spirit infuses the studies described
Safer Surgery
xxiv
and also, I believe, accounts for the richness and depth of understanding achieved
across disciplines.
Second, these studies show a considerable sophistication in the development
of measures. There is of course due attention to methodology and technical
issues, but also recognition of the subtleties of teamwork and that communication
does not only have to be recorded but also understood. Even silence may have
multiple meanings, which will not be apparent to the casual observer. A researcher
might take years to fully understand this environment and the meaning of such
communications, but a team of researchers and clinicians can together reveal the
nuances and subtleties.
Third, the studies almost all concern safety and yet are not dominated by the
issue of error. These researchers are concerned to understand how safety is created
and eroded in the uid interplay of clinical work. Certainly, both clinicians and

researchers need to understand failure and the many hazards of the operating
theatre; but the study of failure is in a sense only a necessary step in the more
general quest to understand how success is achieved and how safety can be gained
or lost in a moment.
Finally, these studies carry lessons beyond their immediate focus. Although
this book is apparently conned to the operating theatre, it points to much wider
themes of relevance to safety in healthcare. Many authors speak, directly or
indirectly, of the wider inuences on teamwork in the operating theatre and the
need to address these issues if theatre teams are to reach their full potential. These
issues include stafng levels, organizational constraints and trade-offs, failure to
train in teams, inter-professional rivalries, and the difculties of engaging staff in
safety procedures. In this sense the operating theatre, and the mirror these studies
hold to it, is a microcosm of the healthcare system. If you read this book you
will learn a great deal about the operating theatre, but also a great deal about the
progress and challenges of patient safety across the whole of healthcare.
Preface
George Youngson
Since the primitive beginnings of operative surgery, surgeons have had a need
to work with assistance, even if it was, in those early times, merely for the
purposes of physical restraint. As surgical and anaesthetic practice became more
sophisticated, so were the tasks becoming more complex and the demand on the
surgical team ever increasing. It is only recently, however, with surgery becoming
an ever more complex and technology-based clinical science that the dynamic and
interaction between all members of the surgical team has become more important
and seen as an element that contributes to a successful outcome or not as the
case may be. As the severity of illness being treated increases and potency of the
therapeutic surgical tools becoming ever greater, so does the risk of the treatment
and the potential for harm. The safety of patients and their continued well-being
while under operative care is therefore not a recent nor novel concern – but there
is a new and increasing recognition of the need for a standardized approach to

communication, leadership and teamworking in the operating theatre, if the team
is to work at maximum efciency and if error of understanding and performance
between individual team members is to be avoided.
The Royal College of Surgeons of Edinburgh (RCSEd) has a long tradition
of trying to build upon surgical standards of care and to further promote safe
surgical practice; it has created a specic forum around which both technical
but also nontechnical aspects of operative performance can be researched,
discussed and developed. The Patient Safety Board of the College has formed
out of developmental research on non-technical skills utilized by surgeons during
their operative performance. Working in concert with the University of Aberdeen
and surgeons in Edinburgh, Dundee, Aberdeen and Inverness a more scholastic
approach to the recognition, development and teaching of non-technical skills
during operative surgery has evolved.
The need for a better appreciation of the potential benets and hazards accruing
from interpersonal behaviours and the cognitive performance of the surgeon,
as well as his/her ability to execute the technical tasks with precision and care,
requires a different approach, a new way of thinking, a new language and way of
speaking.
The RCSEd was therefore delighted to play host to this international workshop
involving researchers in the human factors involved in surgery from across the
globe. The college itself had organized the ‘Advancing Patient Safety in Surgery’
(APSIS) conference the previous day, which had set the scene for a paradigm shift
in the way that surgeons lead, follow, communicate, act and think. This book is
Safer Surgery
xxvi
therefore a welcome contribution to the understanding of team performance in the
operating theatre and how I, as surgeon, can maximize the contributions of those
around me, at the same time ensuring my performance is to the best of my abilities
in pursuit of the optimal outcome for my patient.
Chapter 1

Introduction
Rhona Flin and Lucy Mitchell
Background
This book is designed to present a state-of-the-art perspective on a new area of
psychological and medical research where social scientists are engaged with
clinicians in collaborative projects to study surgical teams at work in hospital
operating theatres. Their goal is to improve understanding of the factors shaping
safe and efcient operative performance. Given the importance of anaesthetic,
theatre nursing and surgical tasks for patient safety during an operation, it is
surprising how little scientic investigation of working life has taken place in
this domain. There are very few reports of the culture and behaviour patterns
in surgical and anaesthesia units, apart from some accounts from sociologists
(Bosk 1979, Hindmarsh and Pilnick 2002, Millman 1976), journalists (Ruhlman
2003) and personal recollections from surgeons (e.g. Conley 1998, Miller 2009,
Weston 2009). These provide rich descriptions of an unusual workplace, powerful
professional cultures, considerable technical expertise and behaviours not always
conducive for patient safety. Adverse events for surgical patients are undesirable
but do sometimes happen (Manuel and Nora 2005). The Chief Medical Ofcer for
England recently stated:
Surgery has seen rapid improvements in recent years: however errors do still
occur. Further improvements will need a more detailed understanding of the
prevalence of harm, a change in culture and the use of innovative new tools,
such as surgical checklists. (Donaldson 2008, p. 27)
Yet, compared to other high risk industrial settings, hardly any systematic
research into workers’ behaviour has been carried out in the hazardous task
environment of the operating theatre. High risk workplaces do not provide the
easiest of research subjects but they are an important domain for psychological
research, as Wilpert (1996, p. 78) noted:
Psychology in high hazard organizations is an unusual conception, a eld which
is only gingerly approached by our discipline. It requires a drastic expansion

of received theoretical frameworks and demands incisive steps towards
interdisciplinary cooperation. Barriers to more intensive involvement exist
inside and outside psychology. Nevertheless enough theoretical and practical
Safer Surgery
2
– even survival – reasons exist for psychologists not to pass up the challenge of
helping to contribute to safety and reliability of high hazard systems.
The chapters in this volume have been prepared by clinicians, research
psychologists and other social scientists, working with clinicians in an attempt
to develop our understanding of the behaviours of anaesthetists, surgeons, nurses
and co-workers in the operating theatre and their consequences for patients. This
unique collection is the result of a scientic meeting which was organized by the
Industrial Psychology Research Centre of the University of Aberdeen and was
sponsored by the Royal College of Surgeons of Edinburgh who hosted the event in
November 2007. Research teams who were investigating the behaviour of operating
theatre personnel were invited to participate and somewhat to our surprise (having
anticipated that only a few UK delegates would take part), representatives from
teams based in Australia, Canada, Denmark, Germany, Netherlands, Sweden,
Switzerland and the USA also decided to attend. Travelling across the world in the
middle of the northern winter for a one day meeting in Edinburgh was not possible
for all those invited. Fortunately, three of the North American teams who could not
be at the meeting, agreed to contribute chapters describing their latest work
Our aim in organizing the meeting was to provide an opportunity for researchers
to exchange information on theoretical and methodological approaches suited
to carrying out psychological investigations in the operating theatre, as well as
to share emerging ndings. The material presented demonstrated the range and
quality of some of the most innovative and signicant research being conducted
in the service of surgical safety (the original presentations are available on www.
abdn.ac.uk/iprc). The day was a considerable success with too little time for an
adequate exchange or scientic discussion but a tantalizing array of data and

methods was revealed. In an effort to capture the shared knowledge presented at
this rst gathering of operating theatre behavioural researchers, we decided (and
acknowledge a suggestive email message from Andy Smith, author of Chapter 15)
to produce this edited book.
Overview
The chapters to follow represent different conceptual approaches to the study of
behaviour in operating theatres and they are typically describing work which has
been published very recently or is still in progress. In some cases, authors are
outlining their ideas for studies that are currently under development. They were
all encouraged to provide full references to illustrate the supporting evidence for
their theories and methods and, where possible, to include examples or sources for
the measurement tools they were using to study behaviour.
Opening prefaces and closing commentaries have been contributed by
surgeons, anaesthetists and psychologists, reecting the multidisciplinary nature
of the rest of the book. In Part I, Chapters 2 to 10 describe the latest research with
Introduction
3
new measurement tools that have been designed to record and rate the behaviours
and skills of individuals and/ or teams when working in the anaesthetic room or
the operating theatre. Many of these instruments, being developed for behavioural
measurement and training in anaesthesia and surgery, have their roots in aviation
practices. Part II, consisting of Chapters 11–24, presents a broader range of
different kinds of observational studies of theatre teams or individual clinicians
in action during the induction or recovery from anaesthesia or engaged in surgical
operations. Chapter 25, by Musson, one of the very few physicians with a Ph.D. in
aviation psychology, offers a cautionary perspective on the risks for medicine of
generalizing too readily from the world of aviation.
We hope this collection will prove to be a valuable resource for both practitioners
and researchers in their endeavours to improve safety for surgical patients.
Acknowledgements

We are particularly grateful for the support offered by Professors Rowley and
Youngson of the Royal College of Surgeons of Edinburgh in offering to host the rst
scientic meeting of this new research community. A second, and equally benecial,
meeting was held at Oxford University in July 2008, hosted by Mr Peter McCulloch
and Dr Ken Catchpole. The papers from that meeting are available from: <www.
surgery.ox.ac.uk/research/qrstu/International%20workshop>.
Our thanks go to Guy Loft at Ashgate for all his support and advice during
the preparation of this volume, and to all those who contributed chapters; we are
specially appreciative of all the expert help we received from Wendy Booth in
transforming multiple idiosyncratic interpretations of the Ashgate style manual
into a coherent typescript.
References
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University of Chicago Press.
Conley, F. (1998) Walking out on the Boys. New York: Farrar, Straus and Giroux.
Donaldson, L. (2008) While you were sleeping. Making surgery safer. In Chief
Medical Ofcer’s Report for England and Wales. London: Department of
Health, 27–33.
Hindmarsh, J. and Pilnick, A. (2002) The tacit order of teamwork: Collaboration
and embodied conduct in anaesthesia. Sociological Quarterly 43, 139–64.
Manuel, B. and Nora, P. (2005) (eds) Surgical Patient Safety. Chicago: American
College of Surgeons.
Miller, C. (2009) The Making of a Surgeon in the 21
st
Century. Nevada City, CA:
Blue Dolphin.