Surgery in Safe Hands

BackgroundThe costs of adverse health events represent a significant burden of disease. Management of these adverse events also entails high costs to healthcare systems, reaching up to US$110 516.25 in...

Crises in the operating room, often resulting from human factors, endangers patient safety. Simulation-based training to develop non-technical skills shows promise in managing these crises. This review examines the simulation techniques, targeted healthcare professionals, non-technical skills, crisis scenarios, and evaluation metrics used in operating room crisis management training. Systematic review. MEDLINE, APA PsycInfo and Web of Science databases were searched for peer-reviewed articles published between January 2004 and March 2024. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review protocol has been registered on the Open Science Framework (OSF) (https://osf.io/7bsc8). The inclusion criteria were as follows: (1) The study population comprised healthcare and medical professionals or students; (2) the intervention involved a simulated learning or training experience; (3) the outcomes focused on non-technical skills or crew resource management; (4) the training setting was the operating room (simulated or real); and (5) the learning scenarios depicted a crisis or an adverse event. This systematic review identified 29 eligible articles. The findings highlight the predominance of high-fidelity simulations, primarily targeting medical staff rather than nurses or other healthcare professionals. Training focused on communication, teamwork, situation awareness, problem solving, and decision making, with scenarios mostly addressing patient deterioration. Assessments reached up to Kirkpatrick's Level 3, demonstrating a positive training impact through learners' reactions and learning metrics rather than behavior and organizational results. Despite their effectiveness, current training practices exhibit limitations. Incorporating nurses and other paramedical staff in interprofessional training, as well as emphasizing team-related scenarios and evaluating behavioral changes in practice, could enhance training effectiveness. This has implications for interprofessional healthcare education and skills transfer to real-world settings, ultimately improving patient safety.

Twelve-Month Cost per Responder (CPR) Analysis of Nilotinib and Dasatinib As Front-Line Therapy in Patients with Philadelphia Chromosome-Positive (Ph+) Chronic Myeloid Leukemia in Chronic Phase (CML-CP)

In their paper, Marshal et al. sought to measure the effect of a checklist on the technical and non-technical skills of doctors during a simulated airway problem 1. While the Anaesthetists’ Non-Technical Skills (ANTS) instrument they used has been validated in simulated practice 2, 3, we are not aware of any published data relating to routine clinical practice. This is surprising, since the assessment of non-technical skills is now a routine part of anaesthetic training, and failure to demonstrate appropriate non-technical skills may lead to a failure to progress through anaesthesia training 4. In contrast, the UK aviation industry introduced standardised non-technical skills training instruction in 1998, in the form of ‘crew resource management’, with later development into NOTECHS (non-technical markers). With institutional research and ethical approval, we have recently compared the non-technical skills of 21 volunteer non-consultant anaesthetists (seven female, 16 male) in three hospitals, measured using both normal subjective clinical assessment and ANTS assessment. All clinical supervisors had completed formal, summative assessments on a regular basis, but were not formally trained in the use of the ANTS tool. Out of a maximum score of 16, the median (IQR [range]) overall rating was 14 (12–16 [12–16]). Nine anaesthetists scored 16, with all supervisors scoring at least one subject as 16. Within the four main categories of task management, teamworking, situation awareness and decision making, all ratings were either good or acceptable with no ratings of poor or marginal. There was a median (IQR [range]) of 4 (0-5 [0-20]) positive and 0 (0–1 [0–4]) negative comments per case. We did not expect ANTS scores to be so uniformly high, and believe it unlikely that almost half of study anaesthetists performed at an ‘exemplar’ level with no subject exhibiting poor behaviour. While it is possible that the ANTS scoring system is invalid or that the raters failed to observe correctly, the literature suggests this is unlikely 2, 3, 5. However, that an ‘acceptable’ rating was provided for six anaesthetists despite their failure to complete the mandatory surgical safety checklist, and for 21 anaesthetists despite negative comments’ being offered by assessors, suggests a lack of clarity among assessors in this study about how to apply the standards objectively within the close social interaction that exists between student and assessor 6. These data reinforce the absolute necessity for the assessment of non-technical skills to be undertaken by properly trained assessors 3, 5.

Research has shown that lack of non-technical skills (also called, Crew Resource Management – CRM) contributes to most personal and process safety incidents in high-risk industries. Situational awareness in the most influential non-technical skill. Authors developed a disruptive program to generate situational awareness competencies and improve non-technical skills of front-line employees. The program is called: Permanent Attention. It combines best practices adapted from high-risk industries and industrial psychology science to generate statistically significant improvements in situational awareness competencies through a sustainable approach. The paper shows real case applications from two organizations where the Permanent Attention program has generated significant improvement in the participants’ situational awareness competency and non-technical skills (CRM) acquisition and retention. The program is executed with the learner at the centre of the process. The Situation Awareness Global Assessment Technique (SAGAT, Endsley, and Garland, 2000) is used to measure the levels of situational awareness competency before and after the training, to determine the impact achieved through the program. The ‘Repeated measures – ANOVA’ statistic model is used to scientifically demonstrate the significant impact of the process in the three elements of situational awareness: Attention, Comprehension and Anticipation. The training sessions in-between SAGATs contain theoretical information and practical exercises that equip the participant(s) with fundamentals. Exercises for each element of the situational awareness have been designed to obtain optimal skills. To complement the practice of non-technical skills, employees are exposed to simulations of critical operational situations, so they can demonstrate their leadership, communications, teamwork, decision-making skills in group and learn how to manage stress in such situations. The levels of situational awareness competencies are periodically monitored via practical field-based SAGAT exercises after the training, to ensure a sustained improvement in the participants’ competencies. The feedback provided immediately after each SAGAT is key to let the participant focus on the element(s) of situational awareness that require improvement. Once the feedback is received, the participant is requested to self-evaluate her level on each element of situational awareness. This reinforces self-consciousness and encourages a sense of commitment to improve by conviction, not by imposition. This novel methodology gives the organization a clear metric on the return on the investment the program offers and allows very specific interventions to improve individual and group level non-technical skills across the organization. A truly disruptive method. The paper shows how the Permanent Attention instructional design combines Endsley's research from the aviation and nuclear industries, with Knowles’ andragogy (2015) theory to achieve competency acquisition and retention. Novel approaches such as the SAGAT, are used with scenarios that are familiar to the target population. Participants’ levels of situational awareness competency are measured before and after the training to determine whether a statistically significant impact was achieved through the program. Permanent Attention has been implemented in organizations with a wide range of maturity. Case-studies are presented to illustrate the process, results, and limitations in two leading drilling companies, in which 60 to 70% of incidents had situational awareness as a contributing factor, over last five years. The implementation of the program has brought statistically significant improvements in the competency of employees and the pilot in Colombia has shown early signs of accident reduction.

Human factors and non-technical skills (NTS) have been identified as essential contributors to both the propagation and prevention of medical errors in the operating room. Despite extensive study and interventions to nurture and enhance NTS in anesthesiologists, gaps to effective team practice and patient safety remain. Furthermore, the link between added NTS training and clinically significant improved outcomes has not yet been demonstrated. We performed a narrative review to summarize the literature on existing systems and initiatives used to measure and nurture NTS in the clinical operating room setting. Controlled interventions performed to nurture NTS (N.=13) were identified and compared. We comment on the body of current evidence and highlight the achievements and limitations of interventions published thus far. We then propose a novel education and training framework to further develop and enhance non-technical skills in both individual anesthesiologists and operating room teams. We use the cardiac anesthesiology environment as a starting point to illustrate its use, with clinical examples. NTS is a key component of enhancing patient safety. Effective framing of its concepts is central to apply individual characteristics and skills in team environments in the OR and achieve tangible, beneficial patient outcomes.

1349 Good clinical practice (GCP)

Training teams and leaders to reduce resuscitation errors and improve patient outcome

Excellence in performance and stress reduction during two different full scale simulator training courses: A pilot study

Economic Incentives for Patient Safety Improvement: An Analysis of Hospital Adverse Event Costs and Where They Fall

Anesthesiologists and otolaryngologists are specialists who share overlapping patient considerations because of the proximity of the surgical field and airway. Although many surgical environments benefit from a collegial team dynamic, the interdisciplinary otolaryngologic environment mandates collaboration from anesthesiologists and otolaryngologists for optimal patient outcomes1. Patients undergoing head and neck surgery are at high risk of potentially devastating events if the airway anatomy is distorted secondary to pathologic conditions or previous surgeries. Although many ENT Anesthesia fellowship programs provide exposure to a wide array of clinical cases and development of airway technical skills, the current simulation literature suggests that training programs focus on improvement of procedural skills in silo2–4. However, this is not optimal for prevention or management of high stress situations where crises resource management (CRM) and interdisciplinary team dynamics can affect patient outcome. We would like to encourage every ENT Anesthesia and Surgical training program to consider introducing a comprehensive simulation-based educational component to ensure proficiency in CRM, communication skills, and leadership skills to better manage the rare and critical cases. The use of simulation for interdisciplinary training amongst anesthesiologists, surgeons, and nurses offers flexibility, preserves realism, and enhances patient safety, which makes it ideal for education and assessment of practitioners, regardless of level of training. A wide variety of simulation technology exists with differing degrees of complexity and fidelity that can be used to advance technical skills. Two major classes are part-task trainers and whole-task trainers. Part-task trainers include simple models designed for a specific task. They vary from animal models and mannequins, to more advanced screen-based computer interface. Examples of airway trainers such as the Laerdal adult airway mannequin are capable of mask ventilation, supraglottic airway placement, fiberoptic intubation, as well more invasive procedures of cricothyrotomy and tracheostomy. Slightly more advanced part-task trainers include bronchoscopy devices such as GI-BRONCH Mentor (3D Systems, Littleton, CO) which provide screen-based simulation coupled with tactical psychomotor mechanics. Part-task trainers are important for clinicians to build fundamental skills that can be translated into proficiency in clinical practice. For example, studies have shown a faster acquisition of direct laryngoscopy and improved psychomotor skills on fiberoptic intubations when practiced initially on part-task trainers5,6. In contrast, whole-task trainers (Laerdal SimMan 3G, CAE HPS) are full-scale patient simulators with advanced computer-driven technology and human-modeled physiology that can be altered for desired clinical scenarios. When whole-task trainers are combined with standardized patients and part-task trainers, a hybrid learning environment can be created to incorporate high-fidelity simulation scenarios involving technical as well as nontechnical skills. Team training in the form of interprofessional education (IPE) and interprofessional learning (IPL) is critical for patient safety in the operating room in general, but more so in head and neck cases due to the shared working environment between otolaryngologists and anesthesiologists1. IPE refers to 2 or more professions learning with, from and about each other to improve collaboration and the quality of care, whereas IPL is learning that arises from interaction between members of 2 or more professions7. Rare and potentially disastrous ENT scenarios can be created and implemented, requiring interdisciplinary teamwork and communication for proper patient care. For instance, an in situ simulation course (one that uses actual clinical resources and equipment) at Boston Children’s Hospital teaches teamwork, CRM, and decision-making of high-risk, low frequency airway emergencies to a team of otolaryngology residents, anesthesia trainees, and operating room nurses8. Scenarios such as foreign body aspiration, the bleeding airway, or airway obstruction requiring a surgical airway can be simulated using a hybrid approach with mannequins and standardized patients. These complex educational modules can enhance the learning process and joint coordination of care for both specialists9,10. A rarer emergency includes the airway fire scenario, which not only tests the nontechnical skills and treatment, but also introduces the “fire triad” (oxidizer, ignition source, and fuel), and creates heightened awareness of anesthetic and surgical management to avoid such a disaster11–13. In situ simulations can also be conducted before implementation of new protocols to assess efficiency, to identify disruptions to workflow, and to evaluate various aspects of patient care such as systems-based errors and integration errors. At Johns Hopkins, an interdisciplinary difficult airway response team was created to manage hospital wide airway emergencies and incorporation of in situ simulations proved to be an invaluable tool to probe the system and to identify defects in resources14. A comprehensive, high-fidelity simulation curriculum incorporated into the ENT anesthesia fellowship allows the refinement of psychomotor skills for advanced airway as well as development of nontechnical management skills. Furthermore, when deliberate stressors are added to a fully immersive simulation involving participants in anesthesiology, otolaryngology and nursing, an opportunity is provided to enhance IPE and to facilitate multidisciplinary collaboration. A study conducted on advanced cardiac life support skills showed that adding extreme emotional stressors to a simulated scenario demonstrated an increased retention of skills and knowledge, as well as better performance of advanced cardiac life support15. Another study revealed that a negative outcome to the patient during simulated independent practice led to better retention of clinical skills upon retesting as compared with those who performed in a simulated supervised practice (where a superior helped intervene to prevent the negative outcome)16. The debriefing period that follows allowed the participants to reflect on individual practice and teamwork to identify weak links and areas of improvement for patient safety and care. Simulation has been used successfully as an assessment tool for medical students, residents, nurse anesthetists and practicing anesthesiologists17–20, as well those deemed incompetent21,22 or those retraining to reestablish competence23. Simulation is an ideal technique for fellowship training, education, and assessment of technical and nontechnical skills, especially in the subspecialty of ENT Anesthesia where unfamiliarity of rare ENT emergencies and crisis situations can have catastrophic implications. We urge that every ENT Anesthesia fellowship consider developing and incorporating simulation as part of the fellowship curriculum. Conflict of interest disclosures The authors declare that they have no financial conflict of interest with regard to the content of this report.

1. Leslie J. Davis, DO*,† 2. David A. Wathen, DO*,† 1. *Saint Louis University School of Medicine, St Louis, MO 2. †SSM Health Cardinal Glennon Children’s Hospital, St Louis, MO For those who work in health-care, it is not difficult to think of examples from our careers where patient safety has been compromised, whether that be a near-miss event or an outcome with actual patient harm. To Err Is Human: Building a Safer Health System was released by the Institute of Medicine in 1999 and brought light to the magnitude of the problem of adverse safety events in health-care in the United States. Since that time there has been an impetus in hospital systems to address and remedy the causes of these issues. Although many improvements have been made, these serious adverse safety events, including death, continue to occur. Most articles published in the area of patient safety focus on interventions made in an adult patient population, but these issues occur across the board and similarly affect pediatric patients. In this review, we focus on 4 articles published with data from patient safety programs implemented at pediatric academic medical centers in the United States. Many principles used in these studies originate in the aviation industry as a response to major airline disasters. One primary principle is known as “crew resource management,” which encompasses the use of nontechnical skills such as situational awareness, teamwork, and communication to identify safety threats and create solutions to these issues. These changes have led to significant improvements in flight safety. Although this may be an imperfect comparison, many of the themes can be applied to a health-care setting. The first theme seen throughout successful programs …

Adverse events (AEs) remain a challenge in tertiary healthcare with incidence rates of 4% to 14%, where half are potentially preventable. Reported patient safety strategies rarely involve changing the practices of an entire academic institution and maintaining sustainability. We hypothesize that implementing an effective patient safety strategy (PSS) improves hospital-wide AE rates, cost avoidance, and patient safety culture. A 3-stage hospital-wide PSS was implemented from 2012 to 2016, involving a top-down, bottom-up approach in a 1171-bed academic institution. The primary outcome was the incidence, preventability, and severity of hospital-wide AEs, calculated through the Institute of Healthcare Improvement, Global Trigger Tool method (incidence), National Coordinating Council for Medication Error Reporting and Prevention tool (severity), and a preventability decision algorithm (preventability). Secondary outcomes include hospital-wide cost savings and patient safety climate survey results. A total of 15,120 random chart reviews were performed across 430,868 admissions from 2012 to 2018. Overall, AE rates decreased from 11.6% to 5.4% (R2 = 0.71, P = 0.017). The incidence of preventable AEs declined from 5.7% to 2.0% (R2 = 0.80, P = 0.006). The severity of AEs reduced, with the proportion of category G, H, and I AEs decreasing from 8.4% (2012) to 2.6% (2018). A total of 15,960 hospital-wide patient safety climate surveys were administered from 2011 to 2016, demonstrating an improvement in hospital-wide percentage positive patient safety grade from 46.5% pre-PSS to 58.3% post-PSS implementation. This was accompanied by an 82% increase in voluntary event reporting, and cost savings of 20,600 bed-days and U.S. $29.2 million upon completion of stage 3 (2012-2016). The hospital-wide PSS resulted in significant improvements in the incidence and severity of AEs, healthcare cost savings, and patient safety culture, demonstrating sustainability for 7 years.

Teaching nontechnical skills in surgical residency: A systematic review of current approaches and outcomes

Non-technical skills are interpersonal and cognitive skills involved in safe performance and preventing adverse events during surgery. it is necessary to dominate the non-technical skills to ensure patient safety. This study has aimed to assess the validity and reliability of Oxford Non-technical skills 2 system (Oxford NOTECHS 2) in Iran and to evaluate surgical teams' non-technical skills in orthopedic surgery wards. This cross-sectional study was conducted in Tehran, Iran during 2015. The level of evidence is III based on Canadian Task Force on the Periodic Health Examination. We followed the Beaton's guideline for Persian translation and cross-cultural adaptation of the checklist. In this study, 60 orthopedic surgical team members working in two selected public hospitals were selected by cluster random sampling method.Oxford NOTECHS 2 system which is consisted of four subscales including leadership and management, teamwork and collaboration, decision-makingand problem-solving, and situational awareness was used to collect the data. The overall mean score of non-technical skills was 69.52±6.64. The mean score for surgery, anesthesia, and nursing sub-teams were 24.98±3.71, 21.12±4.29, and 23.42±3.60, respectively. The teams' scores in total, leadership and management, teamwork and collaboration, problem solving and decision making, and situational awareness at the standard level were 74.70%, 76.95%, 73.75%, 66.87%, and 74.70% of maximum score, respectively. The validity and reliability of the Persian version of Oxford NOTECHS 2 scale in Iran was confirmed. The results of this study showed that surgical teams' non-technical skills were at a moderate level in orthopedic surgery wards. The minimum score of the surgical teams' non-technical skills belonged to anesthesia and maximum to surgery sub-team. Using the training programs and setup workshop is recommended to improve the surgical teams' non-technical skills, especially surgery-nursing sub-team.