Teamwork and Patient Safety in Surgery

265 Pages·2013·3.13 MB·English

by  Amit Vats

Teamwork and Patient Safety in
Surgery

Amit Vats
MBBS, MRCS

A thesis presented for the degree of Doctor of Philosophy (PhD)
Imperial College London, Department of Biosurgery and Surgical
Technology

London 2013
To Maa and Pa, and Anuj

2
Abstract

There is a growing concern that adverse events occur frequently in operating theatres.
Adverse events such as wrong site surgery and surgical site infections have a severe
detrimental impact on not only the patient but also the healthcare staff and the services.
Institute of Medicine’s report, ‘To err is human’ highlighted that teamwork failures are a
leading cause of death and suffering. Yet, in surgery, measuring teamwork and
designing interventions to improve teamwork and patient safety in operating theatres
remains an area of research that is largely unexplored. This thesis aims to measure and
improve teamwork in operating theatres to ensure safer surgery. In this project, the
WHO surgical safety checklist was evaluated for its impact on patient safety. The WHO
checklist improved patient safety processes in operating theatres but its impact on
teamwork, intra-operative problems and theatre efficiency was not clearly understood.
Therefore, a framework was developed to measure teamwork failures, equipment
problems and technical failures as surrogate markers of teamwork, patient safety and
efficiency in operating theatres. Equipment failures emerged as a sensitive measure of
teamwork in operating theatres. Teamwork failures were also associated with technical
failures, delay in case progress and patient harm. It emerged that the WHO checklist
can improve teamwork and theatre efficiency and reduce equipment problems in
operating theatres when it is used in its true spirit rather than a tick-box exercise.
3
Acknowledgments
The three years spent in research has been a life-changing journey, travelling through
the ups and downs, imbibing experiences and knowledge, becoming wiser and hopefully
a more sensitive clinician. Without the people who care about me and supported me
during this period, I would not have been able to make this journey.
I would like to thank my supervisors Mr. Krishna Moorthy and Prof. Charles Vincent for
giving me this opportunity. Krishna has been a big pillar of support guiding me through
the uncertainties, offering new challenges and pushing me to realise my capabilities. I
am honored to have him as my supervisor who had faith in me and showed patience in
my not so bright moments. I thank him for his patience and concern. Charles has been a
great inspiration. He has the magical gift of inspiring students to aim high and see light
at the end of the tunnel. Meeting him has always been an invigorating experience that
filled me with confidence to complete what I began. I thank him for his words of wisdom
that helped me in organising my mind and channelising my thoughts.
I thank Kamal Nagpal and Deelchand Vashisht, my fellow researchers who helped me in
collecting and analysing the data; as well as for those interesting brain storming
sessions. I also thank Georgina Blanco and Mostafa Albayeti, who did some great work
under my supervision. I also thank all my colleagues, who have been helpful in making
my life easier during this research, helping me recruit participants, organise meetings
and doing all those important favours that were invaluable, but hardly mentioned.
I also thank Prof. Lord Ara Darzi and Prof. Atul Gawande for developing the WHO Safe
Surgery Saves Lives Project and giving me a chance to be a part of this global effort to
improve safety in surgery.
On a personal front, I would like to thank my wife Anu for being a source of strength and
a driving force…..couldn’t have accomplished this without her. My parents and parents
in-laws for their emotional support, especially Dr.(Col) M.C. Kapilashrami and Dr. Pawan
Vats for their valuable input in the thesis write-up. Big thanks, to all friends and family,
who were in it with me cheering and supporting.
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This research was funded by NIHR and Health Foundation.

5
Declaration

I declare that the research presented in this thesis is my original work and contributions
of other researchers and individuals have been appropriately acknowledged.
‘The copyright of this thesis rests with the author and is made available under a Creative
Commons Attribution Non-Commercial No Derivatives licence. Researchers are free to
copy, distribute or transmit the thesis on the condition that they attribute it, that they do
not use it for commercial purposes and that they do not alter, transform or build upon it.
For any reuse or redistribution, researchers must make clear to others the licence terms
of this work’

6
Table of Contents
Abstract....................................................................................................................................................3

Acknowledgments.................................................................................................................................4

Declaration..............................................................................................................................................6

Figures...................................................................................................................................................12

Tables.....................................................................................................................................................13

Box...........................................................................................................................................................14

Thesis
 outline......................................................................................................................................15

Project
 Hypotheses............................................................................................................................18

Project
 aims..........................................................................................................................................19

Chapter
 1...............................................................................................................................................20

Surgery-­
 a
 complex
 system.............................................................................................................20

1.1
 Introduction.............................................................................................................................................20

1.2
 The
 evolution
 of
 Surgery......................................................................................................................20

1.3
 Early
 challenges
 to
 surgery.................................................................................................................22

1.4
 Changing
 challenges
 in
 surgery.........................................................................................................23

1.5
 Complex
 nature
 of
 surgery..................................................................................................................24

1.5.1
 Surgical
 care
 pathway......................................................................................................................................24

1.5.2
 The
 patient............................................................................................................................................................27

1.5.3
 Operating
 theatres.............................................................................................................................................28

1.5.4
 Surgical
 teams......................................................................................................................................................30

1.6
 Conclusion.................................................................................................................................................32

Chapter
 2...............................................................................................................................................34

Quality
 and
 Safety
 in
 Surgical
 care...............................................................................................34

2.1
 Introduction.............................................................................................................................................34

2.2
 Measuring
 performance
 and
 effectiveness
 in
 surgery..............................................................37

2.2.1
 Outcome
 measures............................................................................................................................................37

2.2.2
 Process
 measures...............................................................................................................................................38

2.3
 Adverse
 events
 in
 Healthcare.............................................................................................................40

2.4
 Adverse
 events
 in
 surgery...................................................................................................................41

2.5
 Operating
 theatres
 and
 adverse
 events..........................................................................................42

2.5.1
 Wrong
 site
 procedures.....................................................................................................................................43

2.5.2
 Retained
 foreign
 body......................................................................................................................................44

2.5.3
 Surgical
 site
 infections.....................................................................................................................................45

2.5.5
 Equipment
 problems........................................................................................................................................45

2.6
 Systems
 approach
 to
 the
 understanding
 adverse
 events.........................................................46

2.7
 Clinical
 incident-­
 learning
 lessons....................................................................................................48

2.8
 Analysing
 clinical
 incidents................................................................................................................49

2.9
 Conclusion.................................................................................................................................................52

7
Chapter
 3...............................................................................................................................................54

Teamwork
 in
 surgery.......................................................................................................................54

3.1
 Introduction.............................................................................................................................................54

3.2
 Teamwork.................................................................................................................................................54

3.3
 Teamwork
 in
 high-­risk
 organisations.............................................................................................57

3.4
 Teamwork
 in
 healthcare
 systems.....................................................................................................58

3.5
 Teamwork
 failures
 in
 operating
 theatres......................................................................................60

3.6
 Interventions
 to
 improve
 Teamwork
 in
 surgery.........................................................................63

3.6.1
 Team
 training.......................................................................................................................................................63

3.6.2
 Team
 briefings.....................................................................................................................................................65

3.6.3
 The
 Surgical
 checklist.......................................................................................................................................66

3.7
 Conclusion.................................................................................................................................................68

Chapter
 4...............................................................................................................................................69

Measuring
 teamwork
 in
 surgery-­
 a
 review
 of
 literature......................................................69

4.1
 Introduction.............................................................................................................................................69

4.2
 Methods.....................................................................................................................................................71

4.2.1
 Selection
 of
 study...............................................................................................................................................72

4.3
 Findings
 of
 the
 review-­
 Tools
 to
 measure
 teamwork
 in
 surgery...........................................73

4.3.1
 Observational
 measures
 of
 teamwork......................................................................................................73

4.3.2
 Questionnaire
 based
 surveys........................................................................................................................78

4.5
 Conclusion.................................................................................................................................................84

Chapter
 5...............................................................................................................................................85

An
 overview
 of
 research
 programme
 and
 methodology......................................................85

5.1
 Introduction.............................................................................................................................................85

5.2
 Mixed
 methods
 research......................................................................................................................85

5.3
 Methodology.............................................................................................................................................86

5.4
 Conclusion.................................................................................................................................................92

Chapter
 6...............................................................................................................................................93

Impact
 of
 WHO
 surgical
 checklist
 on
 teamwork
 and
 patient
 safety.................................93

6.1
 Introduction.............................................................................................................................................93

6.1.1 Intervention- The WHO surgical safety checklist (Figure 6.1)..................................................94

6.2
 Aims............................................................................................................................................................97

6.3
 Methods.....................................................................................................................................................98

6.3.1
 Study
 Design.........................................................................................................................................................98

6.3.2
 Participants
 and
 materials.............................................................................................................................98

6.3.2.1 Sample..............................................................................................................................................................98

6.3.3
 Data
 collection.....................................................................................................................................................98

6.3.5
 Data
 analysis......................................................................................................................................................102

6.4
 Results.....................................................................................................................................................103

6.4.1
 Patient
 safety
 processes
 and
 clinical
 outcomes.................................................................................103

6.4.2
 Teamwork...........................................................................................................................................................106

6.4.3
 Impact
 of
 the
 checklist
 on
 theatre
 efficiency.......................................................................................108

6.5
 Discussion..............................................................................................................................................109

6.6
 Conclusion..............................................................................................................................................112

Chapter
 7.............................................................................................................................................113

8
Theatre
 teams’
 perception
 of
 impact
 of
 WHO
 checklist
 on
 teamwork
 and
 patient

safety....................................................................................................................................................113

7.1
 Introduction..........................................................................................................................................113

7.2
 Aims.........................................................................................................................................................114

7.3
 Methods..................................................................................................................................................115

7.3.1
 Study
 design.......................................................................................................................................................115

7.3.2
 Participants
 and
 materials..........................................................................................................................115

7.3.3
 Data
 collection..................................................................................................................................................116

7.3.4
 Data
 analysis......................................................................................................................................................117

7.3.5
 Quality
 assurance
 of
 data
 analysis
 and
 interpretation...................................................................118

7.4
 Results.....................................................................................................................................................119

6.4.1
 Benefits
 of
 the
 WHO
 checklist....................................................................................................................119

7.4.2
 Barriers
 to
 WHO
 surgical
 checklist
 implementation.......................................................................121

7.4.3
 How
 to
 improve
 checklist
 compliance
 and
 resilience.....................................................................130

7.5
 Discussion..............................................................................................................................................134

7.6
 Conclusion..............................................................................................................................................136

Chapter
 8.............................................................................................................................................137

Design
 of
 an
 ethnographic
 framework
 of
 teamwork
 failures
 to
 understand
 patient

safety
 and
 efficiency
 in
 operating
 theatres.............................................................................137

8.1
 Introduction..........................................................................................................................................137

8.2
 Aims.........................................................................................................................................................138

8.3
 Methods..................................................................................................................................................138

8.3.1
 Design...................................................................................................................................................................138

8.3.2
 Participants
 and
 materials..........................................................................................................................139

8.3.3
 data
 collection...................................................................................................................................................139

8.3.4
 Data
 analysis......................................................................................................................................................140

8.4
 Results.....................................................................................................................................................145

8.4.1
 Case
 over
 view..................................................................................................................................................145

8.4.2
 Teamwork
 failures..........................................................................................................................................148

8.4.3
 Communication
 failures...............................................................................................................................148

8.4.4
 Co-­‐ordination
 failures...................................................................................................................................148

8.4.5
 Situational
 awareness
 failures...................................................................................................................149

8.4.6
 Shared
 mental
 model,
 planning
 failures
 and
 Knowledge
 based
 failures................................149

8.5.7
 Technical
 failures............................................................................................................................................149

8.4.8
 Distractions........................................................................................................................................................150

8.4.9
 Equipment
 problems.....................................................................................................................................150

8.4.10
 Correlation
 between
 observed
 and
 self-­‐reported
 teamwork....................................................150

8.5
 Discussion..............................................................................................................................................151

8.6
 Conclusion..............................................................................................................................................155

Chapter
 9.............................................................................................................................................156

Understanding
 teamwork
 related
 equipment
 problems
 and
 their
 impact
 on
 patient

safety
 in
 operating
 theatres-­
 a
 multicentre
 study.................................................................156

9.1
 Introduction..........................................................................................................................................156

9.2
 Aims.........................................................................................................................................................156

9.3
 Methods..................................................................................................................................................157

9.3.1
 Study
 design.......................................................................................................................................................157

9.3.2
 Participants
 and
 materials..........................................................................................................................157

9.3.3
 Data
 collection..................................................................................................................................................159

9.3.3.1 Equipment Self report.............................................................................................................................159

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9.3.4
 Data
 analysis......................................................................................................................................................161

9.4
 Results.....................................................................................................................................................162

9.4.1
 Process
 map.......................................................................................................................................................162

9.4.2
 Prevalence
 of
 equipment
 problems.........................................................................................................165

9.4.3
 Variability
 between
 sites..............................................................................................................................167

9.4.4
 Observational
 analysis
 equipment
 problems......................................................................................170

9.5
 Discussion..............................................................................................................................................173

9.6
 Conclusion..............................................................................................................................................176

Chapter
 10..........................................................................................................................................177

Addressing
 equipment
 problems
 in
 operating
 theatres-­
 an
 interview
 study
 to
 explore

underlying
 factors
 and
 solutions................................................................................................177

10.1
 Introduction........................................................................................................................................177

10.2
 Aims.......................................................................................................................................................177

10.3
 Methods................................................................................................................................................178

10.3.1
 Study
 design....................................................................................................................................................178

10.3.2
 Participants
 and
 materials........................................................................................................................178

10.3.3
 Data
 collection................................................................................................................................................178

10.3.4
 Data
 analysis...................................................................................................................................................180

10.3.5
 Coding
 reliability...........................................................................................................................................180

10.4
 Results..................................................................................................................................................180

10.4.1
 Organisational
 and
 Management
 Factors..........................................................................................183

10.4.2
 Work
 environment.......................................................................................................................................185

10.4.3
 Team
 Factors..................................................................................................................................................186

10.4.4
 Individual
 Factors.........................................................................................................................................188

10.4.5
 Task
 Factors....................................................................................................................................................189

10.4.6
 Proposed
 solutions
 for
 equipment
 problems...................................................................................190

10.5
 Discussion............................................................................................................................................194

10.6
 Conclusion...........................................................................................................................................196

Chapter
 11..........................................................................................................................................198

Effective
 WHO
 checklist
 use
 and
 its
 impact
 on
 teamwork,
 problems
 in
 operating

theatres
 and
 patient
 safety...........................................................................................................198

11.1
 Introduction........................................................................................................................................198

11.2
 Aims.......................................................................................................................................................199

11.3
 Methods................................................................................................................................................200

11.3.1
 Study
 design....................................................................................................................................................200

11.3.2
 Participants
 and
 materials........................................................................................................................200

11.3.3
 Data
 collection................................................................................................................................................201

11.3.4
 Data
 analysis...................................................................................................................................................203

11.4
 Results..................................................................................................................................................204

11.4.1
 Quality
 of
 checklist
 use
 correlates
 with
 intra-­‐operative
 failures.............................................204

11.4.1.1 Variability in checklist use in operating theatres....................................................................204

11.4.1.2 Quality of checklist use.......................................................................................................................205

11.4.1.3 Observed events and failures in operating theatres............................................................207

11.4.2
 Quality
 of
 checklist
 use
 correlates
 with
 theatre
 teams’
 perceived
 benefits
 of
 WHO

checklist..........................................................................................................................................................................208

11.4.3
 Quality
 of
 checklist
 use
 correlates
 with
 the
 theatre
 teams’
 perceived
 level
 of
 teamwork.
............................................................................................................................................................................................209

11.5
 Discussion............................................................................................................................................210

11.5.1
 Variability
 in
 checklist
 use........................................................................................................................210

10