Wednesday, June 1, 2016



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. ( 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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