Safety blog posts: Blog post Number 5 Experts, checklists, and attention to detail

Specialization and super-specialization have their good points but all of us are aware the bad points. Seeing the big picture can be a problem for the specialist who may become tunnel visioned. The tendency to seek specialization in the cradle of medical school only worsens this problem. Patients lament the absence of an all around knowledgeable family physician however is it possible to find such a well-informed physician any more or has the complexity of medicine made the mastery of such an expansive knowledge base all but impossible for mere mortals?

Atul Gawande, M.D, a well known author of medical and popular literature treated this subject in his book “The Checklist Manifesto”. Dr. Gawande compares the master builder of yesteryear to the team of construction professionals who must coordinate their team members to build complex modern skyscrapers of today. This excerpt is taken from a book review of “The Checklist Manifesto” at SFAGate.com

“Centuries ago, he writes, builders used to be a lot like today’s doctors, where a “Master Builder” was given total autonomy to construct projects like Notre Dame and the U.S. Capitol building. But making skyscrapers became so mind-bogglingly complex that no one builder could handle it. So builders created elaborate production checklists (they “ensure that the knowledge of hundreds, perhaps thousands, is put to use in the right place at the right time in the right way”) and, more important, specified key communication tasks between experts like elevator installers and engineers. Today, less than 0.00002 percent of buildings fail though they’re more complex than ever.”

Two concepts identified above apply to this blog post about patient safety. One is the issue of total autonomy of a person with a project (you and your medical problem are the project) and the other is the introduction of the concept of key communication tasks and elaborate production checklists to help prevent building failure. We will come back to this book and Dr. Gawande again more than once in future blog posts.

So we have a problem. The family physician of the past who knew quite a bit about everything medical and surgical had the advantage of not being overwhelmed by the mind-boggling complexity of modern medicine. The family physician or surgeon of today when compared to the master builder finds it necessary to seriously ramp up communication and should realize that reliance on checklists simple or elaborate is not a sign of weakness, but a way of paying attention to the details of patient care in an increasingly complex medical and surgical universe. The doctor who professes to know everything about all medical fields is either a rare genius or a fool. Observation power coupled with being a real expert physician is what counts. BY THE WAY my definition of an expert physician or surgeon: An expert knows what he or she does not know. Taking this analogy a bit further, the general surgeon finds him or herself practicing surgery in the increasingly complex field of general surgery. Years ago general surgery included a not previously existent field called orthopedics. Today no general surgeon in the USA would or could practice most types of orthopedic surgery but will be called upon to recognize or observe the existence of orthopedic problems that may masquerade as general surgery problems, e.g., groin pain from a back problem rather than from a hernia.

Your assignment as the patient student of safety surgical safety: to learn to recognize the expert surgeon who pays attention to details and who knows what they do not know.




The Surgical Never Errors Post number 2

The prima donna in the room

prima donna……a very temperamental person with an inflated view of their own talent or importance.

I am certain that all of the blog readers would be quick to assign the label of prima donna to you know who, me and my brethren surgeons. We prefer to think of ourselves as team leaders with great concern for orchestration of the activities that take place during the operation, more analogous to the conductor of an orchestra. To further refine this analogy, let’s say that the conductor of the orchestra plays concert piano during the performance and acts as the guest conductor. Why guest? because as guest conductor he or she does not choose the players in the instrument sections but has to play along side them. This analogy continues to work because serious professional surgeons rehearse operations, especially complex operations in their heads multiple times before the operation starts.

Most of us would prefer to not have a prima donna surgeon as our surgical team leader. The last thing we need is a hard to get along with narcissist leading a team that doubtless does not respect the surgeon and may even dislike the person.

When you are anesthetized or sedated, you will not be able to observe your surgeon’s personality traits, however when you are fully conscious, awake, and alert in the surgeon’s office pay attention to your surgeon’s interaction with others. Surgeons of either sex may act out in the office. For the purposes of this discussion I will assume that the patient is not a narcissistic prima donna but we all know too well that some patients may possess this unflattering trait as well. BTW we do our best to prune patients of this type out of our practice. We can tell much about patients by the way they treat office staff. I usually tell a patient who treats my staff with no respect that we and the patient are not a good mix….no chemistry.

Do not be fooled by a pompous surgeon. Pomposity does not imply exceptional surgical skill. Observe how the surgeon interacts with staff. As HCPs we are professionals who should empower and respect staff, not denigrate, abuse, or embarrass the staff. Such bad boy or bad girl behavior should be obvious to patients and warn that the surgeon may be prima donna. Surgeons who have the opinion they they are better than every one with whom they work set up a power dimension index prone to error occurrence especially if they believe that they are too good to be the cause of an error. The staff feels inhibited to say something to this type of surgeon for fear of retribution, being called on the carpet, and perhaps belittled. The staff member observes this kind of surgeon possibly making a serious error will remain silent and permit the error to occur even if that means the patient will be injured. Believe me, you do not need this type of surgeon to operate on you.

What about cultural differences between team members and how that also may have an effect on power dimension index? We will go into this politically incorrect area next time.

Have a great day and thanks for reading my patient safety blog!




Safety Blog post: Team Communication part1

Safety blog posts: Blog post Number 3

“Team” members in the operating room.
Who are these people and what do they do?

I recently attended the Society of Endoscopic and Gastrointestinal Surgeons (SAGES) annual meeting. During one of the slide presentations, the words team and expert appeared on the screen. We all expect those who render care to us in the operating room to be experts and to be members of a team. To further refine the use of these terms, the patient expects not a team of experts, but an expert team.

Few surgeons have the good fortune to operate with the same team members every time they operate. I think of the situation as being akin to a pickup baseball game of my youth. When you showed for the game you had a good idea of the skills of the potential team members and how well they performed as a team member. The surgeon usually does not pick the team members for a given operation any given day. An anesthesiologist assigns anesthesia coverage for the room and a nurse makes nursing and the surgical tech assignments for the operation.

I listed the job silos above as team members from different disciplines: anesthesia, nursing, surgery (the surgeon), the surgical technician, and the surgeon’s assistant(s). Verbal communication with this team has traditionally been open loop communication. The military use closed loop communication. The difference: the person to whom a request is directed verbally acknowledges hearing the request during or just before execution of the request. I consider myself to be very lucky when I get to work with a surgical tech or any other team OR team member who communicates using closed loop communication. The surgeon’s gentle command assumes that the person to whom the request is directed is actually in the operating room. Team members who leave to fetch something, go on any type of break, etc. rarely announce their departure nor does the person who assumes responsibility for the leaving team member announce their name and assumption of duty.

Now the tradition of using open loop communication can really cause confusion. Let’s say that the surgeon requests that the anesthesiologist named “Randy” who started the operation do something like raise the height of the operating table. The surgeon directs the request to Randy who has unbeknownst to the surgeon been relieved by Samantha. The request to Randy by name to change the operating table height may go unheeded, especially if the request goes to Randy. This leads to impersonal commands such as “Anesthesia, please raise the height of the operating room table 6 inches” that may make Samantha feel a bit affronted.

What does a surgical tech do? The short answer: the surgical tech performs many of the tasks that a scrub nurse of the past used to do such as hand the surgeon instruments and sutures upon request. For most operations, scrub techs scrub with the surgeon while the nurse assigned to the patient’s operation “circulates” in the room. The circulating nurse is a registered nurse and has education, skills, and knowledge of an RN. The nurse functions as a patient advocate in addition to the other assigned responsibilities. Only the RN, not the surgical tech can enter data into the patient’s record.

More information at the link below.
Failures in communication and information transfer across the surgical care pathway: interview study Original research The British Medical Journal http://bit.ly/1iNX9Sh




System Error: One type of Communication Failure in the operating room

Safety Blog Posts: Blog post number 2

System Errors

I will discuss various types of systems error in this blog that result in or may result in lapses of patient safety. There are numerous possible types of system errors. Let’s tackle this one first.

Lack of effective staff Communication Part 1

There are numerous opportunities for errors to occur due to poor communication in any industry; medicine and surgery are no exception.

Staff Empowerment

Lack of staff empowerment by the health care provider (HCP) remains one of the most insidious causes of communication error. The need to have team members with flattened hierarchy enhances team performance. The Dutch psychologist Geert Hofstede studied team performance and is well known for his observations regarding Power Dimension Index (PDI)
http://geert-hofstede.com/dimensions.html

Many students of operating room safety compare operating room team performance to the crew that flies an airplane. Malcolm Gladwell in his excellent book “The Outliers” discusses how power dimension index as described by Hofstede in his cultural studies has had an adverse effect on airline safety. Similarly, PDI may have an adverse effect on team performance in the operating room and other areas of patient care.

Here is an excerpt from the current issue of General Surgery News wherein John Paige, MD, associate professor of clinical surgery, LSU Health New Orleans School of Medicine discusses a problem with PDI. The discussion demonstrates how PDI contributed to team dysfunction in an operating room where the team was getting ready to perform a groin hernia operation.

“The Surgeon’s Lounge
ISSUE: MARCH 2014 | VOLUME: 41:

Dear Reader,

Welcome to the March issue of The Surgeons’ Lounge General Surgery News. In this issue, John Paige, MD, associate professor of clinical surgery, LSU Health New Orleans School of Medicine, New Orleans, replies to a very timely and interesting operative scenario in which human error is highly possible, but where trainees and other team members are strongly discouraged from voicing concerns, or questioning decisions of the attending (senior) surgeon, even when error is very evident and may negatively affect the patient………..”
Please click on the link that will take you to this article by Dr. Paige in the current issue of General Surgery News http://bit.ly/1kJLLrV

In the next post I will discuss how you for your own safety as the patient can recognize the presence or absence of a flattened hierarchy in a team of health care providers.

Last Update: April 08, 2014




The Surgical Never Errors. Post Number 1

Safety Blog Posts: Blog post number 1

Safety, Surgeons, Staff, Systems and a Culture of Safety

Your concerns as a patient should be to understand patient safety for the benefit of yourself, your family, and your loved ones.
One of my goals is to make you more safety sophisticated so that as a patient you gain skills for recognizing safe and unsafe situations and systems. Your concerns then have to do with recognizing “Culture of Safety“.

Safety or lack of it depends on Surgeons, Staff, Systems working safely with active communication taking place. in a safe system an error can be put in motion by one of the care providers but stopped by another health care provider (HCP) before it occurs and injures a patient .

I am a surgeon by trade and surgical safety comes to my mind first although surgical patients can be harmed by medical errors such as medication administration errors. Let’s get started with an area that need not be confusing but has become a bit confusing for all of us.

As we discuss problems with surgical safety of patients be mindful that even though the surgeon may execute an error the “never” errors the patients have other HCP’s who may participate in causing the error (this means a system error may be operational)

What are never errors in surgery?

Originally the errors of doing the wrong operation on the correct patient, operating on the incorrect body part of the patient (wrong side, site), or operating on the wrong patient.
These never errors were first described by Ken Kizer, MD. The information that follows immediately is taken from the entry at another web site. I suggest that you click on the link after you finish reading this post.

AHRQ Patient Safety Network

Background

“The term “Never Event” was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors (such as wrong-site surgery) that should never occur. Over time, the list has been expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable. The NQF initially defined 27 such events in 2002. The list has been revised since then, most recently in 2011, and now consists of 29 events grouped into 6 categories: surgical, product or device, patient protection, care management, environmental, radiologic, and criminal.”

What can we learn from this excerpt? Basically that when we discuss never errors that today we have to specify which area we are discussing. I am choosing to start with the area with which I am most familiar namely the surgical never errors; errors of doing the wrong operation on the correct patient, operating on the incorrect body part of the patient (wrong side, site), or operating on the wrong patient. Many surgical discussions include unintentionally leaving objects inside of a patient with the side, site, patient with this group of errors. I will not include this type of error.