Patient Safety in Neurosurgery and Neurology

Andrea Halliday, M.D. Oregon Neurosurgery Specialists

Disclosures

None

A Routine Operation

Patient Safety

Patient Safety

What human factors contributed to this bad outcome? – Halo effect – Task fixation – Excessive professional courtesy – Complacency – Passenger syndrome

Patient Safety

The 1999 publication To Err is Human concluded that medical errors cause 98,000 deaths annually. In 2005, an article published in JAMA

indicated that despite the call for a 50% reduction in medical errors over 5 years the death rate due to medical errors had not change significantly.

Patient Safety

However, in this same JAMA article, team training in Labor and Delivery led to a 50% reduction in harmful outcomes in premature delivery, such as brain damage. The implementation of rapid response

teams led to a 15% decrease in cardiac arrests.

Patient Safety

Effective teams mitigate human factors that lead to error. The science of teamwork skills and training

has been studied in the US military and commercial aviation for the past 20 years.

Patient Safety Cockpit or Crew Resource Management was

developed in the 1970s after the Military Inspector general identified that 70% of aircraft-related fatalities were a result of human error and poor teamwork.

An article published in Surgery in 2007 found that teamwork and communication problems were the strongest predictors of surgical errors.

Patient Safety

What are the barriers to effective team work in medicine? – Healthcare professionals are educated as

individuals and trained separately within their disciplines.

– Patient care is provided by clinicians who are compartmentalized into separate disciplines, the “silo” approach to health care.

Patient Safety

What are the barriers to effective teamwork? – Teamwork concepts are rarely taught in the

curricula of most health-care professional training.

– Medical teams have a dynamically changing team membership.

– Hierarchical nature of medicine – Disruptive physician behavior

Patient Safety

According to a 2006 J Am Coll Surg article disruptive behavior occurs across the entire spectrum of care but is more prominent in high stress-areas. The service areas most likely to

experience disruptive behavior included the operating room, intensive care units and emergency departments.

Patient Safety

The medical specialties ranked highest by nurses and physicians as having the greatest frequency of physician disruptive behaviors included general surgeons, cardiovascular surgeons, cardiologists, orthopedic surgeons and neurologists.

Patient Safety

The Joint Commission on Accreditation of Healthcare Organizations reported that 70% of all adverse events result from a communication error.

Nurses report a reluctance to call physicians who engage in disruptive behavior.

Disruptive physician behavior discourages members of the healthcare team from speaking up.

Patient Safety

Essential components of effective teams – Leadership – Situation awareness – Mutual support – Communication

Patient Safety

Effective Team Leaders – The leader is not a doer – The role of team leader may transfer from one

team member to another – Assigns team roles – Makes decisions through collective team input – Empower members of the team to speak up and

challenge, when appropriate

Patient Safety

Situation monitoring – The process of actively scanning and assessing

elements of the situation to maintain an accurate understanding of the situation in which the team functions.

– This awareness of the situation is shared with team members allowing the team to be more adaptive and flexible.

Patient Safety A shared mental model results from each team

member maintaining his or her situational awareness and sharing relevant information with the team.

Effective teams possess a shared understanding of the procedure or plan (shared mental model), which allows teams to mitigate and correct errors before they occur or cause harm to the patient.

Patient Safety

Mutual support – Effective teams place all offers and requests for

assistance in the context of patient safety – Team members foster a climate where it is

expected that assistance will be actively sought and offered

– All team members are expected to advocate for the patient in a firm and respectful manner (two-challenge rule)

Patient Safety

Communication – Good communication skills are essential for

effective teamwork – Effective communication is brief, clear, specific,

timely and respectful. – Facilitates the development of mutual trust and

a shared mental model.

Patient Safety Tools and strategies for effective teamwork

– Briefs – Huddles – Debrief – Two challenge rule and CUS – SBAR – Closed loop communication – Checklists for Hand-offs – In situ simulation

Patient Safety

Briefs – Held for planning purposes – Clarifies the roles of the team members – Opens line of communication – Ensures a common understanding of the plan of

care and potential problems – Encourages every member of the team to view

error mitigation as his or her responsibility

Patient Safety

Huddles – Provide team members with an opportunity to

update each other on emerging or significant changes in the patient’s status

– Tool for assessing the need to change plans – Allows for the reassignment of roles if

necessary – Ensures that all members of the team continue

to be on the same page

Patient Safety

Debriefs – Recounting and documentation of key events – Process improvement What worked well What did not work well

Patient Safety

Two-challenge rule and CUS SBAR Closed loop communication Handoff checklists

Patient Safety

In situ simulation recreates stressful critical events involving realistic scenarios requiring complex decision making and interaction with multiple personnel. The team experiential nature of in situ

simulations allows for the systematic acquisition of team concepts and skills.

Patient Safety

In conclusion, surgery, acute strokes, trauma and other neurological and neurosurgical emergencies require high functioning teams to produce the best outcomes.