two doctors talking with each other on the hallway wearing surgical clothing
Risk Prevention

Enhancing teamwork in operating theatres

Teamwork is key to reducing human error and improving patient safety in ORs.

Ten years ago two major reports – To Err is Human (USA, 1999) and An Organisation with a Memory (UK, 2000) – highlighted human error and adverse events that patients, particularly those admitted to hospital, suffer. They concluded that one in 10 hospital inpatients was likely to suffer an error during their hospital stay. A decade later, despite hundreds of interventions to improve patient safety, progress was slower than initially envisioned.

A number of different initiatives were subsequently introduced to refocus attention on patient safety. These included mandating minimum nurse-to-patient ratios, reducing working hours, care bundles that improve patient outcomes, safety checklists, advances to the science of simulation and teamwork training.

Team-based approaches are particularly significant, as inconsistencies in treatment have often been attributed to high turnovers in staff. Trials are currently underway to measure the success of:

  • Simulation - ranging from simple bench-top models to task simulators, virtual reality simulators and simulated operating or labour suites for training and assessment of entire clinical teams.
  • Standardisation – creating a consistent means of assessing core skills and performance.
  • Team training – involving three core activities - leading (over years), managing (over months) and coaching (daily)
  • CPT - establishing routines on a long-term basis, objective standards and checklists.

Healthcare as a team objective

A doctor, dressed in workwear, is passing a scalpel to another doctor, during an operation.

In the Institute of Medicine’s ‘To Err is Human’ report strong recommendations were made to translate concepts of aviation team training into the healthcare industry. The aviation ‘Crew Resource Management’ training, developed in the 1970s and early 1980s, inspired the use of simulation, ‘non-technical’ skills training and standardization. Non-technical skills refer to social (e.g. communication), cognitive (e.g. situation awareness) and resource management (e.g. coping with stress).

Both industries share common issues. Both operate in an environment characterised by stress, heavy workloads, often high-risk situations and high stakes decision-making with very consequential errors.

This team-based training recognises that humans have limited capabilities and that, when human limitation meets environmental complexity and constant stress, errors become inevitable.

As teams, rather than individuals, deliver healthcare success is dependent on the quality and effectiveness of communication, as well as monitoring and co-ordination, within the team. If the clinical environment, team effectiveness or individual clinicians compromise these, concentration will be diverted and safety and efficiency will be affected detrimentally.

What makes an effective team?

One of the key factors of effective teams is that they have shared and accurate “mental models” of the task at hand, the available equipment and the skills and responsibilities of team-mates.

With these obvious and objectively measureable success factors, it is relatively easy to reflect whether the team has achieved its goals.

Other factors, which are often overlooked, include the happiness of the team, their commitment to team goals and their ability to pull together as to improve performance together.

Team training – when and how?

3 doctors, wearing surgical masks, are looking into the camera. Surgery equipment’s are shown in the background.

Team training and safety interventions have to be considered as ongoing, continuous disciplines that are embedded within healthcare organisations. Building effective, expert teams, that have a clear understanding of their tasks, their roles and their expected team behaviours is predicted improve patient outcomes even more than those promised by biomedical advances.

Neily and colleagues carried out a clinical study across 108 hospitals in the USA looking at the impact of team training. It documented an overall 18% reduction in post-operative mortality in the intervention hospitals.

But the only way to achieve these levels of success is through systematic team training.

There needs to be a shift from training on real patients to simulation-based training where actual team members train together in a simulated operating theatre environment. Here they can rehearse and perfect effective responses to catastrophic and/or rare crises and introduce novel interventions such as the World Health Organisation (WHO) checklist.

Improving and standardising assessment

Another area that is important to address in patient safety improvement is the current lack of standardised assessment in healthcare. The challenge is to create a systematic benchmark against which to assess or compare performance.

The BJA recommends that regulations are in place to ensure that assessments are fair and reliable, that valid feedback is provided in an effective and sensitive manner. It also suggests that faculty and trainers should undertake extensive training, demonstrate a minimum level of proficiency, and hold an accreditation to apply these measures in practice.

Finally, it recommends that healthcare provider selection should be based on evidence of appropriately validated tasks, and the concept of assessment/selection of the centres should be introduced across specialities, including acute care, surgery and anaesthesia.