COMMUNICATION
AND TEAMWORK FAILURE AS A BARRIER TO ROBOTIC SURGICAL SAFETY MARCO A. ZENATI
In their recent communication ‘Communication and Teamwork Failure as a
Barrier to Robotic Surgical Safety ‘ Marco Zenati makes some excellent
observations in his summary of the issues surrounding communication and
teamwork in the cardiac surgery suite:
1.
The difficulty
level of team communication increases as the number of health care providers
involved in patient care increases.
2.
Team
communication failures are widespread in the CV OR suites inevitably being
associated with poor operative performance and patient injury.
3.
The specialty
field of cardiac surgery is a dangerous and complex area… in recent years
cardiac surgery has experienced a growing complexity of its case mix due to
increasing patients’ age, co-morbidities, and introduction of advanced robotic
technology. The advent of robotics reduces Surgeon situational awareness due to
the narrow visual field and preoccupation of the computer screen as well as
distance and obstructions to verbal communication.
4.
Weigmann found
that cardiac surgeons make an average of 3.5 errors per hour (2007)
5.
El-Bardissi
observed a strong correlation between the occurrence of technical errors and
teamwork failures (51% of teamwork failures affected surgeon-technical team
interactions).
6.
Surgical Safety
should not be assumed by good clinical outcomes- that is, a good outcome may
result in spite of a safety issue. When the outcome is good we tend to be blind
to the safety issues (Outcome bias). Dr. Zenati then recommends that a common
terminology be used to assure that we are accounting for adverse events whether
they result in a bad outcome or not:
a.
System
Vulnerability: exposure to or opportunity for an adverse event
b.
Safety-compromising
Event: Aka near miss, where there is a variation in the expected course of care
that has a potential negative effect on patient safety and puts the patient at
risk for a measurable adverse change
c.
Contributing
factor: conditions or properties that increase the vulnerability of the system
increasing the risk for an adverse event.
d.
Compensatory
factor: the condition or property that decreases the vulnerability of the
system or reduces the severity of an adverse event.
7.
While
non-technical skills (like communication, teamwork, decision making, leadership
and situational awareness) have been associated improved outcomes, until
recently these skills were only trained and assessed informally in
healthcare. Development of behavior
rating systems in healthcare (NOTSS, ANTS, SPLINTS) are on the rise but not in
use universally.
8.
Team situational-related
communication events are directly associated with team situational awareness:
Closed Loop Communication is extremely effective if utilized correctly and
uniformly.
I was very interested in reading this paper as it hit home as I recalled
a conversation with Dr. Eghtesady in 2015 regarding their black box paper Application of the Aviation Black Box Principle in Pediatric Cardiac
Surgery: Tracking All Failures in the Pediatric
Cardiac.
In that paper and in our conversation he revealed that healthcare staff is frequently inattentive even in the
midst of critical phases in events: “videotaping the OR environment revealed
how often individuals were not paying attention, despite their impression
otherwise.” This attitude appeared to
have occurred during critical event phases as well. With our knowledge of the importance of
communication and situational awareness, revelations such as that are
frightening as hell.
Recently Dr. Zenati’s group presented a paper on the use of the HUB
system as a workflow management system to use speech recognition software to
record communication between OR personnel in the midst of complex communication
processes. Using this software, critical steps and sub-steps were tracked and
episodes of communication breakdown noted and staff alerted.
In my conversation with Dr. Zenati, I wondered how successful he has
been at resolving these communication gaps and improving his personal and the team’s
situational awareness.
What other techniques is he using to
engage his team? What is working there that is failing most other places?
Dr. Zenati: “it’s a challenge….” Patient safety is at the front of
everyone’s mind, but everyone is busy to it is not easy to motivate people to
participate in safety research projects. Having said that, as an academic
institution they have protocols for projects they are interested in, which
translates to motivation of surgery and anesthesia coworkers to become involved
as co-authors or to produce other papers.
Regarding the HUB – “with the
advent of complex procedures there is the potential for increased communication
and other error”. The HUB is a programed
system for various common procedures. The system is set to recognize the
various steps in the procedure while it is tracking key conversational
components. It will remind you of the various steps and alert you if there is
any variance. The program guides you
through complex decision processes. The system knows the commands for the
initiation of the portion of the procedure as stated by the team (such as “AP
ultrasound of aorta completed”). The system is also equipped with a timer to
assess that specific critical components are done at the appropriate time and
provide feedback during and at the end of the procedure. The system can filter
out ancillary conversation and you can customize it with your own
vocabulary. At the end of the procedure
it will provide a synoptic report for feedback to determine where you are or
are not in compliance. They have found it very useful in very complex procedures
where multiple teams are involved and the risk for communication breakdown is
very high. It also has proven useful to assist trainees in process improvement.
So what could be next on Dr. Zenati’s research plate? They have a grant
to begin tracking surgical disruptions using vision tracking technology to
assess the degree surgeons are distracted during these disruptions. In
addition, Boston is hosting the first AATS (American Association of Thoracic
Surgery) Surgical Patient Safety Course: led by Thoralf M. Sundt, III, MD (Massachusetts General Hospital
) and Steven J. Yule, PhD (Brigham and Women’s Hospital) June 24-15 2016. (http://www.aats.org/patientsafety/). The agenda includes the following:
-Use a non-technical skills taxonomy
to assess behavior in a simulated video scenario
-Recognize the challenges and
limitations of Human Factors approaches to the assessment of SA
-Identify common causes of and
factors associated with medical errors in cardiac surgery
-Develop mechanisms to collate and
analyze error causation
-Implement effective communication
tools between and within teams, e.g. preoperative briefings, postoperative
debriefings, and hand-offs
Steve Yule and I conversed about
leadership skills previously this year, so this would be an excellent course
for those interested in leadership development in their institutions.
Zenati MA, Maron JK.
Communication and Teamwork Failure as a Barrier to Robotic Surgical Safety Proceedings
of the Third Computer and Robotic Assisted Surgery (CRAS) Workshop. 2013.
Bowermaster R, Miller M, Ashcraft T, Boyd M,
Brar A, Manning P, Eghtesady P. Application of the Aviation Black Box Principle
in Pediatric Cardiac Surgery: Tracking All Failures in the
Pediatric Cardiac Operating Room. J Am Coll Surg 2015;220:149-155.
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