Task, team and technology integration in the paediatric cardiac operating room

Abstract

One of the most potentially valuable paradigms for improving safety in surgery is known as human factors. However, the main use of this approach has been largely limited to aviation-style teamwork training. In this paper two case studies are presented that illustrate the complex interactions between team, task and technology in paediatric cardiac surgery. Both illustrate primarily how the technological co-ordination of the perfusion task is shared amongst the three key team members. The first case study presents two approaches to going onto cardio-pulmonary bypass, one of which demonstrates a range of key risks. The second presents the transcripts of a case of mild exsanguinations that was quickly recovered from. This case illustrates both the complexity of error and the importance of task-based communications for error capture and recovery. The discussion argues for a broader approach to teamwork considerations in the OR.

Introduction

It is now over a decade since the recognition that inherent failures in healthcare systems predisposes to surgical errors that could have an observable impact on patient outcomes in paediatric cardiac surgery [1]. About the same time, studies examining the level of accidental harm in healthcare – the quality “chasm” – sparked a much wider interest in the relationship between harm, systems of care, and individual human performance [2], [3]. As the decade has progressed, this has expanded the understanding of surgical accidents and how errors might be avoided. There is now a greater understanding within healthcare in general of how and why inadvertent injury occurs [4], [5], [6], and of the “systems” approach to safety and quality improvement [7], [8]. One of the most dominant and potentially valuable paradigms for improving safety in surgery is through a set of collective knowledge and techniques derived from scientific management and industrial psychology, known as human factors [9].

Human Factors is the scientific discipline and application of methods to improve the relationship between humans and other parts of a system [10]. It is based on the premise that humans are difficult to change, shaped as they are by genetics and evolution, while systems are more flexibly altered. It is therefore systems that are deficient, unreliable, unsafe, and predispose to human error by matching badly with human abilities and limitations [11]. The aim is to optimise human abilities to achieve better performance, safety, health, satisfaction and overall system performance by configuring a working environment around a well established understanding of human traits and variability.

Patient safety and human factors research has increasingly suggested that within Hospitals in general, operating theatres in particular, and especially paediatric cardiac surgery (PCS), there is a huge capacity for things to go wrong [12]. There is a reliance on individual healthcare practitioners to perform to a high degree of precision both with the individual aspects of care delivery [13], [14] and at a higher order decision making and planning level for the care of the patient [15]. The design, maintenance and availability of equipment are poor [16], and training often omits interpersonal and non technical, cognitive skills that are nonetheless important for successful surgery [17]. Even though a great many process problems, disruptions, and potential adverse events are identified and addressed before they affect the patient, they can still contribute to undesirable outcomes [18].

In this paper two components of the operative process are presented that illustrate the complex interactions between team, task and technology in paediatric cardiac surgery. By doing so, we hope to examine how human performance and outcomes in the OR might be better understood and improved in the future.