2021_Book_TextbookOfPatientSafetyAndClin

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414 in communication skills) supported by a growing body of research, a paradox arises: many nontechnical skills no longer qualify as being ‘nontechnical’. Moreover the term ‘non-technical’ appears to subordinate these skills to their technical counterparts, when in reality the two skill sets are both essential and inseparable, especially during the management of medical crises. In time new terms may be required (e.g. ‘paratechnical’ skills, Clinical Resource Management) to define and describe this group of skills, and to consolidate their true place in the clinician’s armamentarium. 30.1.1 Practical Overview of NTS Training Topics in Healthcare The standard NTS training topics are summarised in Table 30.1 and detailed in the rest of this chapter. It is important to recognise that these skills are intertwined not only with the more traditional skills they support, but also with each other. Proficiency in one non-technical skill is, to no small extent, dependent on proficiency in the others. Newer generations of aviation CRM have introduced new topics, e.g. the acquisition of expertise and managing automation. It is foreseeable therefore that these topics will be incorporated into future clinical NTS training programmes. 30.2 Performance Shaping Factors Most work environments operate on the assumption that adequate training, experience and motivation are enough to ensure successful performance. These prerequisites are necessary Table 30.1 Typical NTS training topics • Performance shaping factors • Planning, preparation and prioritisation • Situation awareness and perception of risk • Decision-making • Communication • Teamwork and leadership but not sufficient, especially in a complex adaptive system such as healthcare. There are many factors that can influence human performance— over long periods of time, from day to day, or in a given moment. Performance Shaping Factors (PSFs) can be classified according to a clinical adaptation of Reason’s ‘Three Buckets’ model [18] where the traditional categories of ‘task’ (factors inherent to the nature of the task), ‘self’ (internal and personal factors) and ‘context’ (environmental factors) are each sub-divided into ‘task/patient’, ‘individual/team’ and ‘workplace/ organisation’ factors, respectively (Fig. 30.1). The ability to identify and evaluate PSFs in everyday practice may be a useful skill for frontline clinicians. The Three Buckets model can be applied both prospectively and retrospectively. In 2008, the UK National Patient Safety Agency launched a Foresight Training Resource Pack [19], based on a simplified version of the Three Buckets model, to help nurses and midwives better foresee clinical risks. This package is currently used in a number of NHS Trusts. As a retrospective incident analysis tool, Contributory Factors Analysis, also known as the ‘London Protocol’ [20], is based on a similar principle, as is the HEAPS incident analysis tool used in Queensland Health [21] and other health networks in Australia. A quick Three-Bucket summary can be used to highlight PSFs relevant to cases presented at, e.g. Grand Rounds or M&M meetings. 30.3 Planning and Preparation Skills S. Prineas et al. Popular culture is full of references stressing the importance of planning and preparation before performing complex tasks: ‘Be Prepared’, ‘Plan the Dive and Dive the Plan’, ‘Luck favours the prepared’, ‘P to the seventh power’ (‘Prior Preparation and Planning Prevents P—Poor Performance’), etc. In teaching hospital settings, medical and nursing trainees are often asked to perform tasks for which they are illprepared. In these efforts they are not only hampered by the opportunistic nature of teaching in
30 Non-technical Skills in Healthcare 415 Performance Shaping Factors Workplace Organisation Location–Central vs Remote Workspace Dimensions Workspace Layout Appropriate Equipment Maintained Equipment Temperature Lighting Alarm Systems Clutter Orderliness Available Documentation Rostered Manpower Lines of communication On Call Backup Noise Ergonomic Design Forcing Functions Knowledge in the World Colour/Other Coding Checklists Humidity Team ‘Self’ Individual Physical health/comfort Fatigue Hunger Stress Boredom Disorientation Insecurity Self-Esteem Familiarity with task Preparation Training Experience Intelligence Personality Language barriers Religious/cultural/moral beliefs New/established Cohesion Clear goals Clear team roles Clear leader Leadership style Authority gradients Shared mental model Distribution of workload Team morale/conflict resolution ‘Context’ Task Organisational Structure Money and resources ‘Task’ Complexity Urgency Novelty Judgement-based Skill-based Management Style Was there Warning? Strategic Planning Patient Age Fragility Pain level Co-morbidities Legal competence Compliance Mental State Emotional state Religious/cultural/moral beliefs Written instructions? Risks - Probability - Impact - Reversibility Fig. 30.1 Performance Shaping Factors. A clinical expansion of Reason’s Three Buckets model Manpower Planning Drills & Protocols Scope of Work Practices Incident Reporting Escalation Protocols Quality Assurance Culture Maintenance Culture Safety Culture Prevailing Legislation Internal Politics Organisational Morale Bullying Culture clinical settings, but also by the culture of ‘see one, do one, teach one’, a tradition that is counter-intuitive to human-factors thinking and seemingly peculiar (among high-risk endeavours) to medical and nursing education. ‘SODOTO’ training has both critics [22] and defenders [23]. Simulation Based Education (SBE) can be used to demonstrate the consequences of poor preparation and planning in a safe setting [24]. While there are a number of system tools that can help and guide staff (orientation days, checklists, pre-prepared procedural kits, etc.), the question arises as to whether there is a set of definable human competencies/aptitudes that optimise planning and preparing for tasks, and whether this can be taught. The answer to the first part of this question appears to be ‘yes’, in that evaluation of planning, preparation and prioritisation skills are key elements of the ANTS behavioural marker system. These help researchers identify ‘good’ and ‘poor’ task management behaviours in simulated settings, with the highest inter-rater reliability of the four main ANTS categories [25]. However, the ANTS system is not designed to address how to train practitioners to plan and prepare better. 30.4 Situation Awareness and Perception of Risk Situation awareness (SA) is defined as ‘the perception of elements in the environment, the comprehension of their meaning in terms of task goals, and the projection of their status in the near future’ [26]. Perception is essentially being aware of and/or gathering available information relevant to a situation. In a clinical context this correlates with taking a clinical history, examining a patient, reviewing the results of investigations and tests, receiving a handover, conducting a
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Textbook of Patient Safety and Clin
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Liam Donaldson • Walter Ricciardi
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Foreword As a member of the 17th le
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Preface Despite the extensive atten
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Acknowledgements The volume editors
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xii Contents 11 Adverse Event Inves
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Part I Introduction
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4 explain how to prepare and update
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6 considered preventable) [11]. Fur
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8 W. Ricciardi and F. Cascini the l
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10 W. Ricciardi and F. Cascini inte
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12 maximized or perhaps even realiz
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14 steps in obtaining, managing, an
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16 quality improvement methodologie
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18 99. Morciano C, et al. Policies
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20 Reason travelled the world makin
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22 For each hospital unit, other do
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24 As head of clinical risk managem
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26 R. Tartaglia Table 2.1 Differenc
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28 R. Tartaglia Open Access This ch
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30 otherwise efficient brains lead
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32 • A routine violation is basic
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34 Table 3.1 Framework of contribut
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36 H. Higham and C. Vincent The con
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38 H. Higham and C. Vincent recogni
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40 H. Higham and C. Vincent Table 3
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42 assessment and prevention was no
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44 of human error, 2nd: 1983: Bella
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46 ment of theories on how to deliv
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48 all times, not only when there i
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50 healthcare, pursued by enthusias
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52 15. National Academies of Scienc
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54 In this chapter, I will reflect
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56 hospital, there may be 50 indivi
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58 medicals, these are part of the
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60 facility and could therefore bec
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62 health. It is hoped that the Che
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64 Medication Without Harm, invites
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66 21. World Alliance for Patient S
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68 death of my late husband, Pat, f
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70 S. Sheridan et al. test. A separ
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72 enced some kind of harm due to h
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74 S. Sheridan et al. member of The
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76 6.7.1 Example: Canada 6.7.1.1 Wo
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78 All stakeholders must accept, va
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Human Factors and Ergonomics in Hea
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7 Human Factors and Ergonomics in H
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Patient Safety in the World Neelam
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8 Patient Safety in the World 95 8.
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8 Patient Safety in the World adopt
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Infection Prevention and Control An
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9 Infection Prevention and Control
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The Patient Journey Elena Beleffi,
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10 The Patient Journey 119 End of e
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10 The Patient Journey 121 Fig. 10.
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10 The Patient Journey advocates) i
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10 The Patient Journey Table 10.2 T
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10 The Patient Journey 7. Internati
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130 from these interactions that pe
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132 Data integration is certainly t
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134 organizational processes, such
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136 Table 11.3 Scheme of contributo
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138 tocol requires one or more exte
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140 system failure. Quantification
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142 8. Carayon P, editor. Handbook
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144 similar industries, in terms of
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146 (2002) argue is a more effectiv
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148 for research in patient safety
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150 hospital in Kenya with focus on
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152 Haines et al. (2002) proposed a
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154 G. Dagliana et al. Fast Track -
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156 G. Dagliana et al. 11. Jha AK,
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Part III Patient Safety in the Main
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162 development of new receptor ant
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164 Physician burnout and the psych
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166 S. Damiani et al. Fig. 13.1 In
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168 mortality and has rapidly becom
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170 ing to patient safety and share
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172 ability to cope with the workin
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174 2. Vlayen A, Verelst S, Bekkeri
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Safe Surgery Saves Lives Francesco
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14 Safe Surgery Saves Lives manner
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14 Safe Surgery Saves Lives not yet
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14 Safe Surgery Saves Lives In a su
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14 Safe Surgery Saves Lives 14.15.1
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14 Safe Surgery Saves Lives • Tea
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Emergency Department Clinical Risk
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15 Emergency Department Clinical Ri
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206 • Pragmatic: in a healthcare
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208 Risks associated with pregravid
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210 Table 16.1 Common and Recurrent
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212 improved clinical surveillance
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214 (only IM wards or all medical w
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216 M. L. Regina et al. Table 17.1
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218 Table 17.2 Types and preventabi
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220 nicians were certain resulted w
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224 Table 17.6 “Debiasing questio
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226 in care. At a minimum, medicati
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228 cation rates there substantiall
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230 well-structured, concise, focus
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232 M. L. Regina et al. Fig. 17.3 W
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236 Table 17.14 Risk factors for as
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238 Table 17.16 Common risk factors
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240 In patients with kidney disease
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242 Table 17.19 Clinical response t
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244 stones. Giordano’s test posit
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246 in practice. Swiss Med Wkly. 20
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248 procedures done by general inte
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250 tion: a systematic review and m
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252 162. Improvement IfH. What is a
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254 and therapeutic strategies, all
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256 direct effect of radiotherapy o
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258 obtaining treatment consent and
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260 A. Marcolongo et al. Table 18.1
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262 A. Marcolongo et al. Toxicities
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264 nies that are aimed at building
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266 A. Marcolongo et al. tissues. B
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268 and breast cancer) and can be r
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270 happened during the first three
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272 40. World Health Organization (
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Patient Safety in Orthopedics and T
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19 Patient Safety in Orthopedics an
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Patient Safety and Risk Management
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20 Patient Safety and Risk Manageme
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Patient Safety in Pediatrics Sara A
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21 Patient Safety in Pediatrics eve
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21 Patient Safety in Pediatrics of
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21 Patient Safety in Pediatrics Cri
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21 Patient Safety in Pediatrics of
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Patient Safety in Radiology Mahdieh
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22 Patient Safety in Radiology The
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22 Patient Safety in Radiology indu
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22 Patient Safety in Radiology CA a
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22 Patient Safety in Radiology Refe
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Organ Donor Risk Stratification in
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23 Organ Donor Risk Stratification
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23 Organ Donor Risk Stratification
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326 M. Plebani et al. Fig. 24.1 The
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328 ical laboratory and the definit
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330 • Findings of external accred
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332 M. Plebani et al. Fig. 24.2 Mod
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334 laboratory medicine professiona
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336 (WHO) website on the incidence
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338 54. Magnezi R, Hemi A, Hemi R.
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340 In 2010 this condition represen
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342 which should be slightly smalle
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344 needed by the pulse waveform to
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346 washed properly prior to steril
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348 ocular reaction without infecti
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350 large retrospective cohort stud
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352 • Lack of appropriate skills.
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354 scription [126]. Furthermore, a
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356 time and knowledge to young doc
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358 48. Barry P, Gettinby G, Lees F
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Page 363 and 364: Part IV Healthcare Organization
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Page 377 and 378: 378 J. Braithwaite et al. Hence, cl
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Page 383 and 384: 384 27.5.3 Social Networks in a War
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Page 411: Non-technical Skills in Healthcare
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Page 433 and 434: Medication Safety Hooi Cheng Soon,
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Page 447 and 448: 31 Medication Safety 31.5 Final Rec
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Page 451 and 452: 31 Medication Safety 453 Open Acces
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Page 457 and 458: 460 Any difficulty encountered by t
Page 459 and 460: 462 32.4.2 The Usability Assessment
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466 S. Ushiro et al. No-fault compe
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468 33.2 The Meaning of “No-Fault
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470 S. Ushiro et al. figure of 2.3
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472 S. Ushiro et al. Childbirth fac
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474 • When cerebral palsy is caus
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476 (c) (d) (e) (f) (g) (h) (i) (j)
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478 115 bpm to 80 bpm and complete
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480 • It is desirable that system
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482 cific monitoring procedures (1)
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484 Res. 2019;45(3):493-513. https:
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486 19. In the most severe cases, t
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488 Phases 3 and 4, strong emphasis
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490 Phases 5 and 6 focus is on the
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492 during a pandemic to promote tr
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494 M. Tanzini et al. the mother, p
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496 All four abilities are necessar
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