Dr Ken Catchpole
Director of Surgical Safety and Human Factors Research
Department of Surgery
Cedars-Sinai Medical Center
Los Angeles
TASK, TEAM AND TECHNOLOGY
INTEGRATION IN SAFETY AND
PERFORMANCE IMPROVEMENT
AIMS

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.
THE SYSTEMS MODEL OF ERROR

Humans:

Primary
Defense

Secondary
Defense

Last
Defense

Complex systems:


BANG!!
are a fundamental component of
ANY system
are uniquely able to function in
uncertainty, and make trade-offs
create safety in complex systems

are inherently unsafe
always function at the limits of
capacity
require safety to be traded for other
aspects of system performance.
HEPARIN PROTOCOLS (CARDIAC SURGERY)

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
Catchpole K (2011). Task, Team and Technology
Integration in the Paediatric Cardiac Operating Room.
Progress in Pediatric Cardiology 32 (2), 85-88.
No recent heparin incidents
“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
THE TRADITIONAL PERSPECTIVE
“Once outcomes (usually mortality) have been correctly adjusted for
patient risk factors, the remaining variance is assumed to be explained
by individual surgical skill.”
Surgeon
Factors
Patient Risk
Factors
+
Outcome
=
Vincent et al: Ann Surg 239(4):475, 2004
THE SYSTEMS PERSPECTIVE
Patient Risk
Factors
“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
Surgical Flow Disruption Factors
Technology
+
Surgeon
Factors
Supervisory
• Equipment design
• Maintenance
• Training
Environment
• Scheduling
• Distractions
• Interruptions
Teamwork
• Communication
• Familiarity
Outcome
• Staffing
Organizational
• Procedures
• Policies
• Resources
=
SYSTEMIC INFLUENCES ON HUMAN PERFORMANCE
Organisation
Environment
People
Tasks
Technology
“HUMAN FACTORS”
Carayon et al. Qual.Saf Health Care 2006, 15 Suppl 1:i50-i58.
TRANSCRIPT OF AN EXSANGUINATION



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
New plan not clearly
13:41 Surgeon asks for more calcium.
Task conflict; attention elsewhere

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.
Fortuitous co-ordination


communicated
Early Mitigation
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 co-ordinated
Catchpole K (2011). Task, Team and Technology
Integration in the Paediatric Cardiac Operating Room.
Progress in Pediatric Cardiology 32 (2), 85-88.
Error goes unnoticed for >120s
Minor
Problem
Types
Co-ordination / communication
Absence
Equipment failure
Equipment Configuration failure
Patient-sourced procedural difficulties
Safety consciousness
Unintended effects on patient
Equipment / Workspace management
Distraction
Perfusion difficulties
Psychomotor-related surgical error
External resource failure
Cannulation difficulties
Procedure-related Error
Vigilance / awareness
Team Conflict
Perfusion difficulties: technical
Expertise / skill failure
Planning failure
Temperature control difficulties
Pre-operative diagnosis failure
Psychomotor Error (general)
Fault resolution
Resource management
Psychomotor-related perfusion error
External pressures
Fatigue
Known problem
Decision-related surgical error
24 Operations
366 minor problems
29 different types
PEDIATRIC
CARDIAC
SURGERY
0
0.5
1
1.5
2
2.5
3
Mean number per operation
3.5
4
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.567-588.
Minor
Problem
Types
Distraction
Equipment / workspace management failure
Safety consciousness
Co-ordination / communication
Expertise / skill failure
416 minor problems
20 different types
Procedure-related Error
Equipment Configuration failure
Patient-sourced procedural difficulties
ORTHOPEDIC
SURGERY
Equipment failure
Vigilance / awareness failure
Absence
Psychomotor Error (general)
Planning failure
External resource failure
Team Conflict
Psychomotor-related surgical error
Resource management failure
Unintended effects on patient
Pre-operative diagnosis failure
Decision-related surgical error
0
1
2
3
4
5
6
7
Mean number per operation
8
9
10
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 978-0-75467536-5
Minor Problems Per Operation (Paediatric Cardiac Surgery)
40
"Low" Risk
Operations
Minor Failures Observed
35
"High" Risk
Operations
30
25
20
15
10
5
0
Level
1
Level 2
Level 3
Level 4
Level 6
Operations by Risk Level
Catchpole et al. (2006). Identification of systems failures in successful paediatric cardiac surgery. Ergonomics 49(5-6).
Minor Problems Per Operation (Paediatric Cardiac Surgery)
40
"Low" Risk
Operations
Minor Failures Observed
35
"High" Risk
Operations
Major Failures
30
25
20
15
10
5
0
Level
1
Level 2
Level 3
Level 4
Level 6
Operations by Risk Level
Catchpole et al. (2006). Identification of systems failures in successful paediatric cardiac surgery. Ergonomics 49(5-6).
MAJOR EVENTS (2003-2009)
(NOT WITH A BANG…….)

Pediatric Cardiac








Orthopaedics


Multiple uncertainty leads to teamwork breakdown, and less tibia.
Vascular


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
Saline given instead of heparin
Neuro

Mix-up between local anaesthetic and saline
From approx 150 observed operations @ 8 sites
[38+24+6 Cardiac; 10+18 Orthopaedic; 20+9 vascular; 6 Neuro; 9 Max Fax;
15?General; 1 Obs & Gyne ]
People prevent catastrophic failures
Avoid problems
Circumvent poor
processes
Make TradeOffs
Support each
other
Capture
Failures
Mitigate errors
TEAMWORK IN THE CARDIAC OR
Catchpole K (2011). Task, Team and Technology Integration in the
Paediatric Cardiac Operating Room. Progress in Pediatric
Cardiology 32 (2), 85-88.
THE ORTHOPEDIC OPERATING ROOM
CN
1A
SN
Anaesthetic
Workstation
Pump
AC
S
Drip
Catchpole, K (2009). Observing Failures in Successful Orthopaedic Surgery. In L. Mitchell and R Flin (eds), Safer
Surgery – Analysing Behaviour in the Operating Theatre.
SURGICAL NOTECHS
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.
104-108.
Dimensions
Elements
Leadership & Management
Leadership
Maintenance of Standards
Planning & Preparation
Workload Management
Authority & Assertiveness
Teamwork & Co-operation
Team building & Maintaining
Support of others
Understanding team needs
Conflict solving
Problem Solving & Decision Making
Definition & Diagnosis
Option Generation
Risk Assessment
Outcome Review
Situation Awareness
Notice
Understand
Think Ahead
Below Standard (1)
Behaviour directly
compromises patient
safety and effective
teamwork.
Basic Standard (2)
Behaviour in other
conditions could directly
compromise patient safety
and effective teamwork.
Standard (3)
Behaviour maintains an
effective level of patient
safety and teamwork.
Exceed(4)
Behaviour enhances
patient safety and
teamwork. A model for all
other teams.
INFLUENCE OF TEAMWORK
16
1
Ineffective Teams
Effective Teams
0.99
Intraoperative Performance
14
10
8
6
4
2
0.97
0.96
0.95
0.94
0.93
0.92
0.91
350
0
0.9
Intraoperative Duration (mins)
Minor Problems
12
0.98
300
250
200
150
100
50
0
Pediatric Cardiac Surgery
Orthopedic Surgery
Catchpole et al.
Improving patient
safety by identifying
latent failures in
successful operations.
Surgery 142(1),
ROBOTIC SURGERY
15.00
10.00
5.00
0.00
COM COO EXT TRN EQ ENV PF SDM IC
FUMBLING FOR THE MENU BUTTON….
Menu Dial/Button
On / Off
Button
HUMAN FACTORS IN DESIGN
Low Control
Compatibility
High Control
Compatibility
SYSTEMIC INFLUENCES ON HUMAN PERFORMANCE
Safety Culture
Resilience
Learning from Accidents
Workspace Design
Geographical distribution
Physical Constraints
Organisation
Environment
People
Selection
Training
Assessment
Tasks
Technology
Task standardization
Roles & Rules
Prediction & planing
Design
Procurement
Integration
“HUMAN FACTORS”
Carayon et al. Qual.Saf Health Care 2006, 15 Suppl 1:i50-i58.
LESSONS FROM F1 AND AVIATION
Technology
Training Regimes
Process Organisation
– Task Allocation
– Task sequence
– Discipline and composure
Teamwork
– Leadership
– Involvement
– Briefing
Threat and Error Management
– Checklists
– Predicting and Planning
– Situation Awareness
Monitor
Ventilator
ODA
Consultant
Anaesthetist
Power
Anaesthetic
Registrar
Pump
Drain
s
Pump
CCC Reg
/ Nurse
Nurse
Nurse
Urine
Surgeon
Multiple specialists
Complex tasks
Complex interfaces
Time pressure
Need for accuracy
OVERVIEW OF THE NEW PROCESS
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
Discussion &
Plan
Anaesthetist then
Surgeon hand over
information using
Information Transfer
Aide Memoir
Group discussion
SAFETY CHECK
Training time = 30 minutes
Anticipation of
problems
Immediate care
strategy agreed
SOME CHALLENGES


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
SUMMARY

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
THANK YOU FOR LISTENING
Dr Ken Catchpole
Director of Surgical Safety and Human
Factors Research
Cedars-Sinai Medical Centre
Los Angeles
ken.catchpole@cshs.org
ken.catchpole@safersurgery.co.uk
ken.catchpole@cshs.org
SELECTED PUBLICATIONS

Catchpole K. (In Press). Spreading human factors expertise in healthcare: Untangling the knots in people and systems. BMJ
Quality and Safety. Accepted 23 March 2013.

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 19th 2013.

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), 807-809.

Catchpole K (2011). Task, Team and Technology Integration in the Paediatric Cardiac Operating Room. Progress in Pediatric
Cardiology 32 (2), 85-88.

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 469-479.

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),180-186

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 12606 reported incidents from the UK National
Reporting and Learning System. Anaesthesia 63 340-346.

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.102-110.

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),
470-478.