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Improving surgical performance through human factors recognition and enhanced team working
Human error is a significant cause of personal and organizational mistakes, and the need to recognize and address human factors (HF), performance optimization and team dynamics is essential to improve patient safety.
Surgical errors are usually multifactorial rather than the fault of one individual: organizational issues, team dynamics and HF are often at the root of many incidents. The World Health Organization (WHO) surgical checklist and aviation-style communication training were designed to optimize surgical performance by mitigating human fallibility and communication challenges. The brief and debrief processes are other performance improvement practices that have been rated favourably when incorporated into healthcare. Stress and fatigue, emotional status, hunger, situational awareness and ergonomics can all lead to error but are often underappreciated.
This chapter aims to raise awareness of both individual and organizational HF, as well as provide techniques to combat human errors that are commonly seen in the operating theatre. An understanding of HF in modern surgery is just as important as knowing the surgical anatomy to improve safety for patients.
Background
Over 70% of air crashes occur as a result of human error rather than technical failure: communication problems potentially account for up to 80% of these. The appreciation of many factors leading to human error, including poor communication, stress, repetition, tiredness, and an acceptance that a certain degree of failure is inevitable, has resulted in significant improvements in air safety. These lessons, especially with regard to ensuring optimized performance, team dynamics and HF, have been applied to the operating theatre environment. The 1999 USA Institute of Medicine report To Err Is Human and subsequent publications have highlighted death from preventable medical errors: errors in surgery were second only to errors in medication as the most common cause of error-related death. Recent estimates place avoidable US patient deaths at over 400,000 per year, placing preventable harm in the top three causes of death. In the UK, it is estimated that there are approximately 4000 deaths per year due to medical error, with a disproportionate amount of harm caused by errors during surgery. Despite the introduction of the WHO Surgical Safety checklist, the number of ‘Never Events’, such as wrong-site surgery, is increasing. While iatrogenic mistakes are relatively rare, near-misses are far more common; analysis of the root causes that follow any incident can help to avoid otherwise preventable errors.
Where do potential human-related problems originate?
Recognition of several identifiable HF common to both aviation and medicine is crucial in helping to minimize error ( Box 2.1 ). These include stress, fatigue and tiredness, lack of effective team working, poor communication and imperfect leadership. Failures contributing to error could include increased perceived or actual pressure to meet waiting list targets; having more patients on an operating list; seeing more patients in a busy outpatient clinic; and working long hours without a break.
Box 2.1
Simplified human factors analysis and classification system (HFACS) relevant to practising surgeons
The different levels are analogous to the holes in the Swiss cheese model (see Fig. 2.2 ), which can line up, causing an error.
Organizational influences within the hospital
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Climate, process and resource management within the hospital
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Communication, training and recognition of human factors responsible for possible error
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Hospital targets and pressures to deliver results (either perceived or real)
Unsafe supervision
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Loss of situational awareness, especially if not recognized by the theatre team
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Inadequate supervision of junior staff
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Failure of the team to know what to do when things go wrong
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Failure of briefings/complacency with World Health Organization checklist
Preconditions to unsafe acts
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Environmental factors: background noise, distractions, lighting, ambient temperature, humidity
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Fatigue, hunger and nutritional status
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Emotional influences (anger, personal issues)
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Tiredness, boredom, communication issues
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Panic
Unsafe acts (less likely)
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Unfamiliarity with changes from what is seen as a ‘normal event’
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Multitasking
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Operating outside of one's area of expertise
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