Safer Surgery x Figure 16.1 The predicted relationship between Behavioral Marker Risk Index and post-operative complications and death 272 Figure 18.1 Connection between medical management and the quality of communication 315 Figure 19.1 Video equipment conguration for orthopaedic surgery 324 Figure 19.2 Mean number of minor failures per operation by type 328 Figure 19.3 Failure source model which links observable minor failures (small boxes) and common systemic causes (large boxes) 330 Figure 19.4 Mean rates of threats (top panel) and errors (bottom panel), with 95 percent condence intervals 331 Figure 19.5 Bland-Altman plot for agreement between two observers 332 Figure 21.1 A model for the study, with the cues that were available to participating surgeons 361 Figure 21.2 Cue utilization across individual surgeons 362 Figure 22.1 Study setting in theatres: infant simulator and anaesthesia work station, anaesthesia nurse (left) and candidate (right) with the mobile ergospirometry unit applied 373 Figure 22.2 Flow chart for simulated scenario and stress measurement 374 Figure 22.3 MetaMax 3B ™ 375 Figure 22.4 Candidate with mobile and wireless ergospirometry device attached 376 Figure 22.5 Salivary cortisol levels during stress (Trier Social Stress Test, TSST) and rest conditions (Nater et al. 2006) 378 Figure 22.6 Salivary alpha-amylase and norepinephrine (noradrenaline) in response to stress (Trier Social Stress Test, TSST) 379 Figure 23.1 Ambulatory electrocardiograms (ECG) and blood pressure (BP) of an anaesthesiologist during elective (top panel) and emergency (lower panel) intubations 391 Figure 23.2 Heart rate (HR) and blood pressure (BP) of an experienced anaesthesiologist obtained by ambulatory monitors (Holler) 392 Figure 23.3 Comparison of task omission (among those tasks shown in Table 23.1) 394 Figure 24.1 The distractions–stress ladder 415 Figure 25.1 An iceberg model for observed behaviours 431 List of Tables Table 2.1 Summary of NOTSS v1.1 evaluation results 16 Table 3.1 PBA domains 30 Table 3.2 Example elements for total hip replacement PBA, taken from T&O curriculum 31 Table 3.3 Global assessment taken from T&O curriculum 33 Table 3.4 Validation worksheet example taken from T&O curriculum 41 Table 4.1 Index procedures within the surgical specialties 50 Table 5.1 Non-technical skill categories examined in the 13 included papers 69 Table 5.2 Examples of scrub nurse interview questions 73 Table 5.3 Interviewee responses categorized as communication 75 Table 6.1 Operative phases and stages of OTAS © 88 Table 6.2 Task completion rates in general surgery (rst study) versus urology (second study) 91 Table 7.1 Summary of rst iteration of the surgical NOTECHS scoring system 106 Table 7.2 Reliability (R wg ) of Oxford NOTECHS tool for 36 dual observed LCs and CEAs 110 Table 7.3 Reliability (R wg ) of Oxford NOTECHS for 12 dual observed CEAs 110 Table 7.4 Reliability of Oxford NOTECHS in 14 cases observed independently with third observer 110 Table 9.1 The A-TEAM scale for assessment of individual team behaviour 139 Table 10.1 Overview questionnaire communication and teamwork in operating theatre 157 Table 10.2 Time frame TOPplus project 158 Table 10.3 Duration of the time out (in seconds) 163 Table 10.4 Duration of the debrieng (in seconds) 163 Table 11.1 The ANTS system: categories and elements 177 Table 13.1 Denitions and examples for categories 211 Table 14.1 Intra-observer agreement over time for the observation system reported at the level of observation categories 231 Table 16.1 Description of domains behavioural markers of team behaviour assessed by the observers 264 Table 16.2 Denitions of measures: patient risk of complications (American Society of Anesthesiologists – ASA – classication), procedure risk (American College of Cardiologists – ACC-score) and outcome (outcome score) 265 Safer Surgery xii Table 16.3 Characteristics of 293 patients and procedures 268 Table 16.4 Description of behavioural markers scores by operative phase, number and percentage of procedures with complication or death, and odds ratios (OR) and 95 per cent condence intervals (CI) for complication or death for less frequent observation 270 Table 16.5 The association of the Behavioural Marker Risk Index with post-operative complications and death 271 Table 17.1 Denitions of types of communicative failure with illustrative examples and notes 285 Table 18.1 Sample of the sample 306 Table 18.2 Category system ‘Problem solving in a team’ 309 Table 18.3 Examples of behavioural markers for evaluating communication in the scenarios used 310 Table 18.4 Items for evaluating medical management (Scenario 1) 311 Table 18.5 Formal characteristics of utterances in the scenarios 312 Table 18.6 Utterances related to team coordination and shared mental models 313 Table 18.7 Utterances related to the team and the problem-solving process 314 Table 19.1 Phases of a typical primary total knee replacement operation 323 Table 19.2 Descriptions and examples of minor failure types 325 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) 347 Table 21.1 Non-technical skills in the rst simulation series 364 Table 22.1 Reference intervals for plasma and salivary cortisol 378 Table 23.1 Task sequence tracheal intubation where X = cross, SpO 2 = O 2 saturation, BP = blood pressure, HR = heart rate, IV = intravenous, CO 2 = carbon dioxide 393 Table 23.2 Monitors used: number of patients (%) of total n=48 at each level of airway management task urgency. Emergency = <10 mins after admission, semi-emergency < 10–60 mins after admission and elective = > 1 hour after admission 394 Table 23.3 Task durations of intubation events. Mean and standard error of duration (in secs) of events in the intubation sequence among 11 elective and 12 emergency tracheal intubation 395 Notes on Contributors Sonal Arora is a doctor of medicine and a trainee in general surgery, with a further degree in psychology. Her research interests include surgical education and training for patient safety, with a focus upon simulation and non-technical skills training. She is currently completing her PhD, entitled ‘Stress, Safety and Surgical Performance.’ sonal.arora06@imperial.ac.uk Bianca Balvert is an OR-nurse specialized in endoscopic surgery in Sint Lucas Andreas Hospital in Amsterdam. She graduated having studied the improvement of OR patient tracking efciency. She is involved in a patient safety project in collaboration with Erasmus MC. b.balvert@slaz.nl Jonathan Beard is a consultant vascular surgeon at the Shefeld Vascular Institute, Professor of Surgical Education at the University of Shefeld and Education Tutor at the Royal College of Surgeons of England. He has published widely on surgical skill assessment and helped to develop the Intercollegiate Surgical Curriculum Project. Jonathan.D.Beard@sth.nhs.uk Doug Bonacum is vice president – safety management for Kaiser Permanente. He leads the development, implementation and monitoring of programme-wide safety management strategies and plans with specic responsibilities for environmental, health and safety, patient safety and clinical risk management. He was formerly responsible for weapons and ships safety as well as nuclear power plant operations in the US Submarine Force. doug.bonacum@kp.org Benno Bonke is an associate professor of medical psychology at Erasmus University Centre, Rotterdam and was trained as a clinical psychologist and psychotherapist. He is the coordinator of medical education in communication skills and professional behaviour in the core curriculum in Rotterdam. B.Bonke@ Erasmusmc.nl John Brookey is assistant medical director of quality for Southern California Permanente Medical Group, a large multi-specialty group that provides care for over three million Kaiser Permanente health-plan members. He is a paediatrician and practises at the Kaiser Permanente Pasadena Medical Ofce. john.brookey@ kp.org Cornelius Buerschaper is a management consultant and human factors psychologist specializing in crisis management. He is a team trainer for medical and Safer Surgery xiv managerial teams using computer simulated games for safety training and is co-author of Crisis Management in Acute Care Settings: Human Factors and Team Psychology in a High Stakes Environment (2007). cornelius.buerschaper@ t-online.de J. Forrest Calland is an assistant professor of surgery in the University of Virginia School of Medicine. His research focuses on outcomes, safety and human factors in high risk environments.calland@viginia.edu Ken Catchpole is a human factors practitioner in the QRSTU, Nufeld Department of Surgery, University of Oxford. Taking a semi-ethnographic approach to understanding the complex nature of error in healthcare, he seeks to evaluate and improve the safety of surgical systems. Ken.Catchpole@nds.ox.ac.uk Jim Crossley is senior fellow in the Academic Unit of Medical Education at the University of Shefeld and a consultant paediatrician in Chestereld. He advises and publishes widely on workplace-based assessment and psychometrics. Trevor Dale is a human factors training specialist and retired airline training captain. With Guy Hirst he is working with the NHS Institute, The Royal College of Surgeons of England and Oxford University Nufeld Department of Surgery. Connie Dekker-van Doorn is an RN with a degree in HRD. She is now working on her PhD in collaboration with Delft University of Technology focusing on patient safety and human factors. c.dekker-vandoorn@erasmusmc.nl Peter Dieckmann is a work and organizational psychologist working with the Danish Institute for Medical Simulation (DIMS) at the Copenhagen University Hospital in Herlev, Denmark. Peter studies the use of simulations for training and research focusing on human factors studies and training of simulation instructors. mail@peter-dieckmann.de. John Duncan is a consultant general and vascular surgeon at Raigmore Hospital, Inverness. He is Clinical Tutor and member of the Specialist Advisory Board in General Surgery for the Royal College of Surgeons of Edinburgh. john.duncan@ haht.scot.nhs.uk Christoph Eich is consultant paediatric anaesthetist and co-director of the Centre for Education and Simulation in Anaesthesiology, Emergency and Intensive Care Medicine at University Medical Centre Göttingen (Germany). ceich@med.uni- goettingen.de Li Felländer-Tsai is a professor and senior consultant in orthopaedic surgery. She is the chairperson of the Department of Clinical Science, Intervention and Notes on Contributors xv Technology (CLINTEC) at Karolinska Institutet and the director of the Centre for Advanced Medical Simulation at Karolinska in Stockholm, Sweden. li.tsai@ki.se Rhona Flin is professor of applied psychology, University of Aberdeen (www.iprc.ac.uk), and she leads the Scottish Patient Safety Research Network (www.spsrn.ac.uk). Her research on safety examines leadership, culture, team skills and decision-making in healthcare and high risk industry. Kenneth T. Fong is a senior managerial consultant in the Pricing Underwriting Department for Kaiser Permanente’s Northern and Southern California regions. Kenneth.t.fong@kp.org David Gaba is a medical doctor (anaesthesiology), Professor of Anaesthesia and Associate Dean for Immersive and Simulation-based Learning at Stanford University School of Medicine. He is also a Staff Anaesthesiologist at VA Palo Alto Health Care System. gaba@stanford.edu Fauzia Gardezi is a clinical research project manager at SickKids Learning Institute in Toronto and a research consultant with expertise in qualitative methodology and critical sociology. fauzia.gardezi@utoronto.ca Emma Giles is a specialist anaesthetist at Sir Charles Gairdner Hospital in Perth, Western Australia. She has a strong interest in teaching and assessing anaesthesia registrars and in patient safety, and is an examiner for ANZCA. emma.k8@gmail. com Ronnie Glavin is a consultant anaesthetist at the Victoria Inrmary in Glasgow. He also carries out various roles for NHS for Education in Scotland (NES). ronnie. glavin@ggc.scot.nhsuk Dawn Goodwin is a social science lecturer in medical education. She teaches courses on various aspects of science, technology and medicine to both medical and social science students. Jodi Graham is a specialist anaesthetist at Sir Charles Gairdner Hospital in Perth, Western Australia. She is a supervisor of anaesthesia training, and her main interests are in education and simulation. jgraham@meddent.uwa.edu.au Suzanne Graham is director of patient safety for Kaiser Permanente. Suzanne has served in multiple roles within Kaiser Permanente at the medical centre, regional and national levels. She has a BSN in nursing as well as Masters degrees in school health and developmental disabilities from San Francisco State University. Her doctoral degree is from a combined programme at Baylor, University of Texas, and University of Houston. Suzanne.Graham@kp.org Safer Surgery xvi Gudela Grote is professor of work and organizational psychology at the ETH Zurich, Switzerland. She is Associate Editor of the journal Safety Science and has consulted on safety management for companies like Swiss Re, Deutsche Bahn AG and the Swiss Nuclear Inspectorate. ggrote@ethz.ch Stephanie Guerlain is associate professor of systems and information engineering at the University of Virginia, USA. Her research focuses on human–computer interaction, particularly information visualization, training system design and the design of decision support systems. guerlain@virginia.edu Leif Hedman is a licensed psychologist and associate professor at the Department of Psychology, Umeå University, expert in medical human factors. He is also an afliated researcher at the Department of Clinical Science, Intervention and Technology (CLINTEC) and the Centre for Advanced Medical Simulation at Karolinska in Stockholm, Sweden. Leif.Hedman@psy.umu.se Guy Hirst founded Atrainability Limited with Trevor Dale in 2002. He recently retired as a training standards captain from British Airways. Since 2001 he has been involved in several research projects training multidisciplinary teams in various healthcare environments. guy.hirst@atrainability.co.uk Graham Hocking is a specialist anaesthetist at Sir Charles Gairdner Hospital, Perth, Western Australia. His main interests are research, education and regional anaesthesia. Gesine Honger is a human factors psychologist specializing in patient safety and management of critical incidents. She is a member of the advisory board of the German Coalition for Patient Safety and co-author of Crisis Management in Acute Care Settings: Human Factors and Team Psychology in a High Stakes Environment (2007). gesine.honger@t-online.de Steve Howard is an associate professor of anaesthesia at Stanford University School of Medicine and a staff anaesthesiologist at the VA Palo Alto Health Care System. showard@stanford.edu Robbert Huijsman is part-time professor of management of integrate care at the department of Health Policy and Management of Erasmus University Rotterdam. He combines his scientic work with a partnership in a healthcare consultancy rm (Zorg Consult Nederland). Rosamond Jacklin is a specialist registrar in general surgery. After graduating from medical school in 2000, Ros undertook basic surgical training and the MRCS, then completed a PhD at Imperial College (2004–2008) entitled ‘Judgment and Decision Making in Surgery’. r.jacklin03@imperial.ac.uk Notes on Contributors xvii Shelly Jeffcott is a senior research fellow at the NHMRC Centre of Research Excellence in Patient Safety and has a background in psychology and the examination of risk and safety in high hazard industries. Shelly.Jeffcott@med. monash.edu.au Geert Kazemier is hepatobiliary and transplant surgeon at Erasmus Medical Centre. He is also responsible for the Operating Room Department at that institution. G.kazemier@erasmusmc.nl Jan Klein is professor of anaesthesiology at the Erasmus University Medical Centre. He developed a special interest in peri-operative patient safety and is the President of the Netherlands Society of Anaesthesiology. j.klein@erasmusmc.nl Michaela Kolbe is work and organizational psychologist and research assistant at the Organization, Work and Technology Group at ETH Zurich, Switzerland. mkolbe@ethz.ch Barbara Künzle is work and organizational psychologist and research assistant at the Organization, Work and Technology Group at ETH Zurich, Switzerland. bkuenzle@ethz.ch Johan Lange is professor of surgery in the department of surgery of the Erasmus University Medical Centre in Rotterdam, the Netherlands. He is Associate Dean of the Faculty of Medicine of the Erasmus University and President of the Committee of Patient Safety of the Dutch Society of Surgery. J.lange@erasmusmc.nl Robert Lasky is a professor of paediatrics and the director of the Design and Analysis Support Services for the Centre of Clinical Research and Evidence Based Medicine at the University of Texas Medical School at Houston. Robert.E.Lasky@ uth.tmc.edu Lorelei Lingard is senior scientist in the SickKids Research Institute and the Wilson Centre for Research in Education, University Health Network and University of Toronto. She is the inaugural holder of the BMO Financial Group Professorship in Health Professions Education Research. lorelei.lingard@utoronto.ca Colin Mackenzie is professor of anaesthesiology and associate professor of physiology at the University of Maryland School of Medicine. His research interests include human factors in emergencies, and trauma resuscitation. He has been continuously funded by Federal grants for the past 18 years. cmack003@ umaryland.edu Marlene Dyrløv Madsen works at the Danish Institute for Medical Simulation (DIMS) as a researcher in patient safety and safety culture. She has a PhD in Safer Surgery xviii patient safety and ethics of patient safety, and holds a Masters in philosophy and communication. mdyrloev@ruc.dk Tanja Manser is a senior lecturer at the Centre for Organizational and Occupational Sciences, ETH Zurich, where she is heading a research group on human performance and safety in complex systems. tmanser@ethz.ch Nikki Maran is a consultant anaesthetist in The Royal Inrmary of Edinburgh and Director of the Scottish Clinical Simulation Centre in Stirling. Her interests are in anaesthesia for emergency surgery, education for patient safety and non-technical skills training and assessment. Joy Marriott is a specialty registrar in obstetrics and gynaecology, currently working towards an MD in surgical education and a Masters of Education at the University of Shefeld. Her research interests include workplace assessment and competency-based selection. Joy.Marriott@sth.nhs.uk Karen R. Mazzocco is a nurse-attorney with 20 years of experience as a surgical director, primarily at the University of Cincinnati where she achieved her BSN and Juris Doctor. She practised law in hospitals in New York and New Mexico. Since 2001, she worked in research in surgical and perinatal patient safety during afliations at Kaiser Permanente in California. Currently, she is afliated with Sharp Healthcare in San Diego, CA, in the evolving eld of patient service and satisfaction. karen.mazzocco@sharp.com Peter McCulloch is clinical reader at the Nufeld Department of Surgery in Oxford. He founded the Quality, Reliability, Safety and Teamwork Unit (QRSTU) in 2005, which focuses on evaluating interventions to improve the functionality of modern healthcare systems. peter.mcculloch@nds.ox.ac.uk Lisbet Meurling is specialist in anaesthesia and intensive care medicine and participant of the Scandinavian Society of Anaesthesiology training programme in intensive care medicine. She is a PhD student at CLINTEC, Karolinska Institutet. lisbet.meurling@karolinska.se Ami Mishra is a surgical registrar on the Oxford rotation, whose MD project examined the value of an aviation-style team training approach to improving safety in the operating theatre. He hopes to maintain his research throughout and beyond his training. ami.mishra@nds.ox.ac.uk Lucy Mitchell is a research assistant in the Industrial Psychology Research Centre, University of Aberdeen, investigating non-technical skills of nurses/scrub practitioners. She previously studied police rearms ofcers’ decision-making skills and was formerly a police ofcer. l.mitchell@abdn.ac.uk Notes on Contributors xix Maggie Mort is reader in the sociology of science, technology and medicine and co-director of the Centre for Science Studies at Lancaster University, UK. An ethnographer, her research interests include new medical technologies, telehealthcare and disaster recovery. m.mort@lancaster.ac.uk Michael Müller is consultant anaesthetist at the Hospital of Technical University and Director of Interdisciplinary Medical Simulation Centre, Dresden, Germany. mp-mueller@web.de David Musson is an assistant professor and Director of the Centre for Simulation- Based Learning at McMaster University in Hamilton, Canada. He received his MD from the University of Western Ontario, and PhD in psychology from the University of Texas at Austin. musson@mcmaster.ca Andrea Nickut is a research student at the Centre for Education and Simulation in Anaesthesiology, Emergency and Intensive Care Medicine at University Medical Centre Göttingen (Germany). andreanickut@web.de Simon Paterson-Brown is a consultant general and upper gastro-intestinal surgeon at the Royal Inrmary Edinburgh and an honorary senior lecturer at the University of Edinburgh. Simon.Paterson-Brown@luht.scot.nhs.uk Rona Patey is a consultant anaesthetist at Aberdeen Royal Inrmary. She is also the Director of the Clinical Skills Centre at Foresterhill and Deputy Head of the University of Aberdeen Division of Medical and Dental Education. r.patey@abdn. ac.uk Diana Petitti is a physician (preventive medicine) and medical doctor (MD) She is Professor in the Department of Biomedical Informatics in the Fulton School of Engineering at Arizona State University. diana.petitti@asu.edu David Pitts is a psychologist with a background in management development. He is Project Coordinator of the UK orthopaedic curriculum (OCAP), Associate Director of Leadership and Educational Development at the Royal College of Surgeons of Edinburgh and Education Advisor to the British Orthopaedic Association. d.pitts@rcsed.ac.uk Catherine Pope is reader in the school of health sciences, University of Southampton. Her research includes evaluations of organizational change and studies of surgical practice. She is currently researching the use of computer decision support in urgent and emergency care, and ambulance handovers.cjp@ soton.ac.uk . 373 Figure 22 .2 Flow chart for simulated scenario and stress measurement 374 Figure 22 .3 MetaMax 3B ™ 375 Figure 22 .4 Candidate with mobile and wireless ergospirometry device attached 376 Figure 22 .5. observers 3 32 Figure 21 .1 A model for the study, with the cues that were available to participating surgeons 361 Figure 21 .2 Cue utilization across individual surgeons 3 62 Figure 22 .1 Study setting. Cardiologists – ACC-score) and outcome (outcome score) 26 5 Safer Surgery xii Table 16.3 Characteristics of 29 3 patients and procedures 26 8 Table 16.4 Description of behavioural markers scores