Safer Australian Surgical Teamwork – Human Factors in Action

My blog, ‘In Safe Hands – Flying High’, described the importance of good communication and teamwork and the importance of these non-technical skills or human factors in ensuring patient safety.

Recently, I had the privilege of being involved in an initiative, ‘Safer Australian Surgical Teamwork’ (SAST) conducted through the Royal Australasian College of Surgeons (RACS) aimed at improving non-technical skills within surgical teams. RACS have conducted programs in non-technical skills for surgeons (NOTSS) for a number of years using the work of industrial psychologist, Rhona Flin from Aberdeen University. Flin’s work also involved identifying anaesthetic non-technical skills (ANTS) and scrub practitioner list of non-technical skills (SPLINTS).

Seeking to broaden the original NOTSS program and develop a program that included all members of the surgical team, RACS invited representation from ACORN, Australian College of Nursing (ACN) and Australian & New Zealand College of Anaesthetists (ANZCA) to participate in a working party to develop a series of human factors workshops conducted at selected rural centres around Australia.

I was honoured to be invited to represent ACORN alongside Elissa Shaw, with fellow perioperative nurses Vicky Warwick, Emma Woodhouse and Rona Tranberg representing ACN. The combined working party met at RACS HQ in Melbourne several times to develop the content and identify presenters for each workshop, organise venues and travel plans. As the whole program was government funded through Rural Health Continuing Education, the venues selected were Albany (WA), Darwin (NT), Bega (NSW) and Traralgon (Vic).

A team, the RACS Faculty, comprising of an anaesthetist, surgeon, one or two nurses and a RACS Project Manager facilitated each workshop.

The presentations, aimed at exploring team dynamics, reflected the non-technical skills identified by Flin’s work in each discipline – situation awareness, communication, teamwork, task management, decision making and leadership.

I presented ‘Situation Awareness’ in Traralgon and at two workshops in Darwin (photo shows  me with Vicky Warwick and NT ACORN Director, Sharon Harding) – quite a contrast in temperature and the sand flies saw me coming in NT causing a very uncomfortable week as I desperately tried to find a relief for the itchy bites! I did find it interesting (and at times challenging) to present to interdisciplinary groups, I wasn’t sure how the surgeons and anaesthetists in particular would react to the content, but there were some great experiences shared which added to the richness of discussions. There was some amusing banter between the disciplines, along with some robust discussion and overall I came away energised by the openness of the groups to embrace new ideas and strategies for improving their local teamwork. I also had the chance to meet new people, caught up with old nursing buddies and enjoyed working with such a committed group of surgeons, anaesthetists and perioperative colleagues, all of whom gave their time voluntarily to participate in this exciting project.Vicky Warwick and Sharon Harding in Darwin

Participants in each centre were restricted to 15 to allow for plenty of interaction and ensure an even spread from each discipline. A combination of didactic sessions, group work, video scenarios, and observational assessments were greeted enthusiastically by all the participants. The evaluations were very positives with participants identifying the following ‘take home’ messages:
• greater team involvement in Time Out process
• get to know your team
• reduce distractions during important phases of surgery (‘sterile cockpit’)
• recognise fatigue amongst team members
• have confidence to speak up and contribute to patient safety

Hopefully the positive evaluations will lead to further funding and more workshops across the country. In particular, it is hoped that local champions for human factors can be identified, so that ‘in house’ human factors workshops can be conducted.

I invite you to view some of the websites related to human factors and keep an eye out for future workshops at your hospital.

Clinical Human Factors Group

Scrub Practitioners List of Non-Technical Skills (SPLINTS)

bye for now

In Safe Hands – Flying High

Recently I was sitting on Qantas flight contemplating the 23 hour journey ahead of me to London when the Captain’s voice came over the speaker system with a cheery greeting. Often I tune out at this stage as I busy myself with seatbelts, headsets and claiming elbow room from my close neighbour! But the name of the Captain stopped me in my tracks – ‘Good afternoon, ladies and gentlemen, this is Captain Richard De Crespigny speaking.’ The name may not be familiar to you, but to me it sent my mind back four years to November 2010 when the same pilot brought stricken flight QF32 back safely from the brink of what could have been one of the worst air disasters.QF32_1

QF32 was an A380 airbus with 469 passengers and crew on board which had just left Singapore on the final leg of the long haul flight from London. Four minutes into the flight an engine blew up, caught fire, severing a number of vital electrical and hydraulic systems within the wing. The resulting catastrophic emergency tested the experience and teamwork of the flight crew to their limits in trying to assess the damage and its consequences for the plane. The good news was that the flight crew were able to land the plane safely back in Singapore. What makes this a somewhat personal story is that I should have been on that flight, but extended my stay in UK by a day, thereby missing this near disaster.

Hearing Captain De Crespigny’s cheery welcome last week got me thinking about what he and his crew must have gone through managing the emergency four years ago. It also made me consider the parallels between the teamwork required in the cockpit during that emergency and similar situations in an operating theatre when good teamwork and communication are vital components of a safe outcome for the patient. I have just watched a recreation of the events on QF 32 and struck me was the calm leadership of Captain De Crespigny as he delegated jobs to his flight crew whilst he took over flying the plane. In one of the many interviews you can view on You Tube, he tells of importance of using his hearing to ascertain how well the engines were working – not relying on the myriad of controls at his disposal, many of which were showing alarms and therefore unreliable. How many times do we in an operating theatre rely on watching monitors rather than use our eyes and ears to tell us the condition of a patient?

One of the roles he delegated during the emergency was to his First Officer who took fifty five minutes to investigate each one of the hundred alarms that had been triggered, with each alarm having its own checklist to work through! Ignoring any one element of the checklist could have meant disaster for the plane and its passengers. How often you see teams going through the motions of our ‘Time Out’ checklist without really engaging with each aspect and how that may put our patients at risk?

The other aspect that struck me watching the recreation was the teamwork of the flight crew and the contributions each made to working out solutions for the many problems they faced. None were afraid to speak up and all were encouraged by the Captain to contribute their thoughts to finding solutions. Are there parallels we can draw between the flight crew and teams in the operating room? How easy or challenging is it for you to speak up if you witness unsafe practices or to voice concern about the way in which surgery is progressing? Hierarchical barriers which once plagued the cockpit are still in evidence in many surgical teams. What can be done about this? We know from the reading reports following adverse events that poor communication and dysfunctional teams are often the root cause of such events. Non-technical skills such as teamwork and communication are just as important to the safe outcome for the patient as the technical expertise the surgical and nursing teams possess.

In my next blog I will describe an initiative with which I have recently been involved aimed at improving multidisciplinary surgical teamwork and communication.

Until then – ‘sit back, relax and enjoy the flight’ – I certainly did.


You can view a recreation of the events that took place on QF32:

‘Airbus A380 (Qantas Flight 32) – Engine on Fire – The Titanic in the Sky Seconds from Disaster’

24 Hours in Emergency

One program that I try to catch each week is the fly on the wall documentary – ‘24 Hours in Emergency’, shown on SBS TV. The main reason that I enjoy it, is that it is filmed at King’s College Hospital, Camberwell, South London which was my training hospital and I love to see the panoramic shots around the local area, spotting haunts that I know so well. Not only did I train at King’s, I grew up just around the corner, so it holds a very special place for me. Plus I love hearing those South London accents belonging to the salt of the earth people who inhabit the surrounding suburbs and were once my neighbours. The program follows the patients who come through the Emergency Department doors in a 24 hour period. King’s is one of the busiest Emergency Departments in the world and has certainly undergone an amazing refurbishment in the years since I was a terrified student nurse working there – not my favourite placement!

The focus of most days is the red phone bringing news of the latest trauma victim which sees the team swing into action – teamwork at its best – everyone assigned their roles by the Team Leader working seamlessly to stabilise and treat their patients. What sets this program apart from other fly on the wall medical documentaries, is the emotional impact of the face to camera interviews with the medical and nursing team – they reveal a lot about their thoughts and feelings as they treat the patients, the responsibility that weighs heavily on their shoulders – something that in the hustle and bustle of a busy department goes unnoticed. There have been many lump in the throat moments whilst I have watched this program. The individual patients and their relatives are followed through their treatment – mostly the outcomes are good and you see the patients many weeks after they have recovered. They provide an interesting insight about what it was like being the patient or a relative coping with the shock of seeing a loved one sometimes at death’s door.

In a recent episode one of the RNs, the night supervisor, found himself admitted as a patient. A casual comment by one of the RNs that his eye looked very bloodshot and he should get himself checked out, led to a colleague taking his blood pressure – 180/110. A barrage of tests followed and revealed he had lung cancer! Surgery and ongoing treatment has seen him back at work and optimistic about the future. All that simply after a casual remark.

Amidst those requiring immediate life saving treatment are the usual collection of chair warmers with minor complaints which could have been treated by a GP. They often, unintentionally, provide the amusing entertainment element of the program!

If you haven’t seen it, it is worth a look from a professional and human interest perspective.

Cheers  Menna

What’s changed my thinking recently?

Have you ever had that moment where you hear something that radically changes your thinking? This happened to me recently while listening to a TED talk about Alice Stewart – one of the youngest women to be elected to the Royal College of Physicians in Oxford. Alice was the epidemiologist who, in the 1950’s made the groundbreaking discovery that x-rays during pregnancy can harm the developing foetus.

I’ve always known about this connection, as I think all women would know if they’ve ever been x-rayed (“Are you pregnant?” /”No” / “Are you sure?” / “Yes…well, pretty sure. Why do you ask?”). I guess I’d never wondered how this was discovered, or perhaps I’d just forgotten about it. Those lectures on radiology from my training days were a long time ago!

Anyway, Alice’s discovery went against the existing views of her medical colleagues. In fact, it took another 25 years for Alice’s research to change medical practice and for the exclusion of pregnant women from x-ray screening to become the norm. This is despite Alice finding that twice the number of children who had died from cancer had mothers who had been x-rayed while pregnant.

Alice was confident in her conclusions not only because she had compelling data but also –  indeed most of all – because her statistician colleague had been unable to prove her conclusions wrong. Yes, that’s right – Alice and her colleague George Kneale collaborated in a most unusual way – and this is what’s changed my thinking recently – they “dared to disagree”. The TED talk I was listening to was first delivered in Edinburgh in 2012 by Margaret Heffernan. It is 12 minutes of inspiration with the potential to change the way you think about yourself, your team and conflict.

Alice Stewart is the starting point in Heffernan’s discussion about communication, thinking and the value of constructive conflict. She suggests that rather than seeking out people who think like you do, you should seek out those who think differently, who challenge and question your conclusions. Only by this, can you avoid group-think and only by this can you do your best thinking. Over to you!

Alice Stewart epidemiologist who discovered link between xrays during pregnancy and childhood cancers

Alice Stewart, the epidemiologist who discovered the link between x-rays during pregnancy and childhood cancers

Bye for now, Sally

These links will open in the same window: You can read the transcript of this TED Talk here or you can watch the video here (YouTube 13 mins). You’ll nee to use your navigation buttons to return to this page.

These links will open in a new window: You can read the transcript of this TED Talk here or you can watch the video here (YouTube 13 mins). Close the new window at the end and you should still be on this page.