© Springer-Verlag London 2015Nader Francis, Abe Fingerhut, Roberto Bergamaschi and Roger Motson (eds.)Training in Minimal Access Surgery10.1007/978-1-4471-6494-4_13
13. The Human Factor in Minimal Access Surgical Training: How Conscientious, Well-Trained Surgeons Make Mistakes
Colorectal Surgery, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX25DW, UK
Colorectal Surgery, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, Somerset, BA21 4AT, UK
KeywordsHuman FactorsNon-technical skillsErrorCommunicationTeamworkBriefings
The former National Patient Safety Agency in the UK estimated that there are about three million admissions to NHS hospitals in England; of these about 300,000 will involve some sort of error that results in harm to a patient, and a further 30,000 patients will die as a result of those errors . This is a higher number that equals the combined annual mortality from breast, prostate and colorectal cancer; a large problem . The vast majority of these deaths are related to human factors and organisational systems so it logically follows that to reduce the number of errors and therefore harm, we need to focus on these areas and how we go about training surgeons to be more aware of their fallibility.
Surgery contributes to almost half of all adverse events and to 13 % of all hospital deaths. Some 40 % of these injuries are committed in the operating room (OR) . Multiple estimates of adverse events in surgical patients have been undertaken and fairly consistently come up with a figure of 20 % [3, 4]. That means that 1 in 5 patients have an error in their care that results in harm of some kind and in 4 % the harm is so severe that they die. The conundrum is this; if surgeons are trained to a very high standard (which they are) so that they are equipped with the skills and knowledge to undertake the most difficult minimally access procedures (or any aspect of medicine for that matter), why do so many mistakes keep happening? The answer comes from further analysis of these errors. Retrospective reviews looking at the underlying cause of these errors showed that only 6 % were related to a lack of knowledge and technical skill . The surgical community can pat itself on the back and say that through the multiple training techniques that are detailed in the rest of this book they are very effective at making sure surgeons of the future are equipped with the technical skills they need. So what about the other 94 % of adverse events? The overwhelming majority (73 %) are related to the human factors that will be described in the rest of this book chapter, the remaining 20 % are related to organisational systems that made error extremely likely (i.e. having patients on non-specialist wards, saline and lignocaine in very similar bottles, etc.) [5, 6]. Although MAS carries significant benefits to the patient the operative environment imposes substantial physical and cognitive strain on the surgeon increasing the risk of error .
In this chapter the importance of human factors will be outlined as case presentations. The chapter also covers the various different components that make up human factors and finally how surgeons can be trained to be safer.
Story 1 – The Danger of Hierarchy
A consultant surgeon was performing a laparoscopic sigmoid colectomy to remove a malignant polyp in the distal sigmoid colon. The polyp had not been clearly tattooed so the surgeon performed an on–table colonoscopy to identify the site. He then used diathermy to mark the serosal surface. After mobilisation of the colon and division of the vessels he came on to dividing the bowel. He placed his stapler proximal to the mark he had made. The nurse softly said that she thought that the stapler was in the wrong place but the surgeon did not heed this comment and went on to divide the bowel. The nurse did not feel she could say anything more and that the surgeon must be right. On histological inspection it was clear that the line of transaction went across the polyp and the patient had to return to the OR for a further resection.
The term Human Factors (otherwise known as non-technical skills) relate to a variety of domains: communication, teamwork and leadership, decision making, situational awareness, stress and fatigue . These traits are consistent across all human actions. Until recently most of the science relating to them came from industries outside health care, predominately aviation and the military.
Of all the domains of human factors communication is the most important and is the most significant factor in the majority of errors . This is not a controversial statement; surgeons are well aware that communication is critical to good patient care . Despite this, very little emphasis is placed on inter-professional communication during undergraduate and post-graduate training. Healthcare tends to rest in a world of informal communication, where important messages are transmitted in haphazard ways that make mistakes almost certain. When OR performance is assessed at least 30 % of communication episodes result in failure visibly affecting system processes, including inefficiency, team tension, resource waste, delay and procedural error [8, 10, 11].
Structured, formalised communication results in better and safer care for patients . Two recent examples of this are the WHO checklist (Box 13.1) and the SBAR tool (Box 13.2). Both of these systems originated in the aviation industry where they have been shown to reduce error and thereby the number of crashes and deaths. Formal communication like this is essential in healthcare but getting widespread adoption has been difficult. Most hospitals in the UK are using the WHO checklist in the peri-operative period but often these checks are not done properly and the full benefits are not realised .
Story 2 – Saved by a Flat Hierarchy
A consultant was supervising a trainee performing a laparoscopic appendicectomy. The patient’s blood tests showed significantly raised inflammatory markers and on initial laparoscopy the pelvis contained significant amounts of turbid fluid. The appendix appeared mildly inflamed. The trainee performed the appedicectomy under close supervision. The consultant (who was distracted by thoughts of the complex laparotomy that would follow this case) told the trainee to wash out and close up. The trainee questioned this decision saying he was not happy that the appendix could explain the blood tests and the significant amount of turbid fluid. The consultant listened and heard what the trainee was suggesting and they then followed the small bowel along and found the real pathology, a perforated Meckel’s diverticulum.
Operative briefings and debriefings are also now becoming common practice in the OR. These meetings allow the important points of the day to be discussed, thus improving efficiency and safety and, equally importantly, can influence the often steep hierarchy that exists in the OR [14, 15]. Although there was significant resistance to the initial implementation of pre-operative briefings, once they staff became familiar with them and the tangible benefits associated they have become a core component of most OR practice.
Team Working and Leadership
Nothing in healthcare is done by individuals alone; work is done in teams. It therefore follows that how these teams function is critical to the quality and safety of the care provided . Surgeons work in multiple teams; in the OR, intensive care, surgical wards and the outpatients. Team members have to support each other, solve conflicts, exchange information and co-ordinate activities . When successful teams are analysed, many factors are common, but the underlying factor without which teams cannot be successful is the interpersonal relationships that team members have. Without a harmonious group climate teams will never work to their optimal abilities. This is not to say that everyone has to be falsely nice to each other but if there is not mutual respect between all team members problems will occur.
As interpersonal relationships are so important major effort needs to be spent ensuring the strength of these relationships. Briefings, if done well, can contribute to this. Everyone must have a voice and feel that they contribute. At the start of effective briefings all staff must introduce themselves and by that very action of saying aloud their names they become more included and are more likely to speak up later if they have concerns.
Leadership is also crucial, not only by giving a clear direction to the tasks at hand but by ensuring that the authority gradient is kept to a minimum. There is no doubt that a team needs a leader on whom ultimate authority for decisions rest but the hierarchy around this needs to be kept at an absolute minimum. There are two problems with a steep authority gradient. Most obviously and dangerously if the people at the bottom of the hierarchy feel unable to speak up they will not bring potential safety problems to the group’s attention. This has resulted in many incidents that have resulted in harm and death to patients. Stories 1 and 2 demonstrate the impact hierarchy can have. In the first story the nurse was well aware that the surgeon was dividing the bowel in the incorrect place but after softly mentioning it once, did not feel she could mention it again. In the second story the flatter hierarchy allowed the junior to speak up and prevent a potentially disastrous mistake from occurring. The OR team has many people in it and if they all feel that they can contribute to decision making and error prevention then patients will be safer.
Less well known is the impact that authority has on the leader. If someone exists at the top of a steep authority gradient their ability to understand and empathise with those beneath them diminishes, this has been shown in multiple behavioural science experients [17, 18]. So just by the act of promoting someone up the hierarchy the capacity to take appropriate decisions decreases.
Situational Awareness and Decision making
Situational awareness is the simple act of knowing what is going on around you and having an understanding of how that might change in the future. It is crucially important that all members of the team have the same understanding of what is going on; they share the same situational awareness. This is often not the case in the OR. This is another area where the pre-operative briefing can be helpful by ensuring that all members of the team are sharing the same understanding of the immediate world around them.
Story 3 – A Fatal Diagnostic Error
The on-call surgeon in a rural hospital in Eastern Africa was called in the early hours one morning. The message (which was hand delivered, there were no bleeps) stated that there was a 65 year old man in urinary retention but the night nurse could not catheterize the patient. The on-call surgeon went and briefly reviewed the patient at about 5-00 am. Urinary retention from benign prostatic hypertrophy (BPH) was a common diagnosis in the population the hospital served. The surgeon tried to catheterise the patient but could not get any urine back. The harder tipped catheters were kept in theatre which was locked and the on-call theatre team would have to be woken up. As the patient seemed reasonably comfortable the surgeon decided to give some analgesia and then sort the catheter out when the theatre opened at 8 am which was now only 2½ hours away.
When the patient was brought to theatre the surgeon immediately realised that the patient was now shocked and commenced resuscitation which was ultimately unsuccessful and the patient died. During the resuscitation it became clear that the diagnosis of benign prostatic hypertrophy was incorrect and in fact the patient has sigmoid volvulus and acute renal failure (hence no urine on catheterization).
Situation awareness forms the first part of the process of decision-making. Once information is taken in by the person or team then a series of potential options can be devised; one of these is selected and that becomes the plan. In story 3 the surgeon incorrectly assessed the situation; his situational awareness was wrong and so his decision-making process was fatally compromised. Why did the surgeon make the wrong assessment? There are several human factors that were at play but the most significant was the very common medical tendency of tunnel vision. The surgeon had been given the diagnosis, urinary retention secondarily to benign prostatic hypertrophy (BPH). It is a natural human tendency to try and fit the situation to our pre-conceived ideas. New information is accepted or rejected, based on how well it fits to the original thought; this is called conformational bias. In this case the surgeon noticed the facts that fitted his diagnosis; lower abdominal pain, no urine on catheterisation, and that the patient was the correct demographic for BPH. He disregarded, or paid less attention to, the facts that did not fit the diagnosis; lower blood pressure, tachycardia, tympanic abdomen and the fact that the catheter appeared to be going in smoothly. Earlier that day he had also managed a patient (correctly) with BPH; this tendency to diagnose recently seen conditions is called the availability heuristic.