2021_Book_TextbookOfPatientSafetyAndClin

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428 Which style is better? In one theoretical model, the answer depends on the situation. For example, in a complex ill-defined scenario involving an experienced multidisciplinary team, a consultative approach would seem more constructive; on the other hand, in a well-defined time-critical emergency with a novice team, invoking an autocratic drill would be more efficient. This is the concept of situational leadership—that good leaders adapt their style according to the available human resources and the needs of the situation [144]. Correlations have been found between Myers- Briggs personality types and leadership styles [145]. This suggests that clinicians in charge may gravitate naturally to one or other leadership style—autocratic or consultative, ‘task- specialist’ or ‘social-specialist’—according to their personality. It is important therefore for clinicians to recognise their own natural tendencies, and (e.g. through simulation) to seek out training in being the opposite; naturally deferential types could practice being more assertive; naturally autocratic types could practice active listening. In this way the leader is better prepared to apply whatever appropriate style a situation may demand. 30.7.16 Transferable Command and Control In helicopter medical retrievals, the pilot is in overall tactical command and can modify or abort the mission at any time. However, as the rescue moves through different phases, different team members hold operational command, directing other team members (even the pilot) during the performance of key tasks. The pilot is in charge of getting the team to the site; the winchman oversees getting the medical crew to ground; the medical officer assesses the patient and is in charge of initial resuscitation; the paramedic ensures the patient is safely secured on the stretcher; then it’s the winchman again, in charge of getting the patient and crew back into the helicopter; then back to the pilot, getting the chopper to the receiving hospital; and finally the medical officer is in charge of handing the patient over to the receiving emergency team. This concept of ‘taking the con’ is a form of transferable leadership [146] or transferable command and control, and can be applied to many multidisciplinary situations in healthcare, e.g. running an operating theatre, a busy diabetes outpatient clinic, or a community mental health service. It requires multidisciplinary team leaders to know and trust the different skill sets of their team members, and to balance autocratic and consultative leadership styles (see Sect. 30.7.15—see above). 30.8 Teaching Non-technical Skills Training to ensure effective decision-making for patient safety should contain components of deliberate practice and feedback [147]. It is essential to expand the number and range of scenarios that decision makers have in their repertoires, and to develop the sense of what is important. High- and low-fidelity simulations are increasingly being used for research and training in dynamic domains such as healthcare (e.g. operating rooms; [148]). Low- fidelity approaches such as the ShadowBox method are effective ways to expose decision makers to a range of possible decision scenarios with coaching from experts on cues to monitor, issues to worry about, and interpretations of ambiguous situations [149, 150]. Higher-fidelity training may include contextual features, such as the hospital or operating environment, and incorporate communication and teamwork in realistic simulations. Over the last decade there has been increasing interest in the interprofessional team training— doctors, nurses and allied staff training together as opposed to training within their craft groups— to overcome the challenges of cultivating effective multidisciplinary teams and patient-centred care, particularly in crisis management scenarios [151, 152]. 30.9 Summary S. Prineas et al. Supported by a large base of theoretical literature on human factors in both medical and nonmedical domains, non-technical skills are fast becoming an established and indispensable build-
30 Non-technical Skills in Healthcare ing block of patient safety, and increasingly incorporated into many undergraduate and postgraduate healthcare curricula. A growing body of research suggests that good NTS training improves healthcare processes and outcomes, mostly in simulated environments, but also in real-world environments, especially in critical care fields such as anaesthesia, surgery and emergency medicine. While there remain substantial challenges in developing methodologies to better define and refine the role of NTS in improving healthcare outcomes, this domain is a rich seam for future study. References 1. Nasir ANB, Ali DF, et al. Technical skills and nontechnical skills: predefinition concept. Presentation at the IETEC’11 Conference, Kuala Lumpur, Malaysia. 2011. http://ietec.apaqa.org/wp-content/uploads/IETEC-2011-Proceedings/papers/ Conference%20Papers%20Refereed/Monday/MP2/ MP2.320.pdf. Accessed 20 Oct 2019. 2. Beaty D. The human factor in aviation accidents. New York: Stein & Day; 1969. 3. Vernon HM. Accidents and their prevention. Cambridge: Cambridge University Press; 1936. 4. Helmreich RL, Merritt AC, Wilhelm JA. The evolution of crew resource management training in commercial aviation. Int J Aviat Psychol. 1999;9(1):19–32. 5. Job M. “Did he not clear the runway – the Pan American?” (The 1977 Tenerife air disaster). In: Air disaster, vol. 1. Australia: Aerospace Publications; 1994. p. 164–80. 6. Job M. “I don’t like this…” (The 1979 Mt Erebus air disaster). In: Air disaster, vol. 2. Australia: Aerospace Publications; 1996a. p. 61–82. 7. Job M. “Mayday! We’re not going to make it to the airport!” (The 1978 Portland air disaster). In: Air disaster, vol. 2. Australia: Aerospace Publications; 1996b. p. 36–46. 8. Muñoz-Marrón D. Human factors in aviation: CRM (Crew Resource Management). Psychologist Pap. 2018;39(3):191–9. 9. Leape LL. Error in medicine. JAMA. 1994;272(23):1851–7. 10. Gaba DM, Fish KJ, Howard SK. Crisis management in anesthesia. Philadelphia, PA: Churchill Livingstone; 1993. 11. Risser DT, Rice MM, Salisburt ML, Simon R, Jay GD, Berns SD, The MedTeams Research Consortium. The potential for improved teamwork to reduce medical errors in the emergency department. Ann Emerg Med. 1999;34(3):373–83. 429 12. Institute of Medicine. To err is human: building a better Health system. Washington, DC: National Academies Press; 1999. 13. Department of Health [UK]. An organization with a memory: report of an expert group on learning from adverse events in the NHS. London: Stationery Office; 2000. 14. Fletcher G, Flin R, et al. Anaesthetists’ Non- Technical Skills (ANTS): evaluation of a behavioural marker system. Br J Anaesth. 2004;90(5):580–8. 15. Yule S, Flin R, et al. Development of a rating system for surgeons’ non-technical skills. Med Educ. 2006;40(11):1098–104. 16. Mishra A, Catchpole K, McCulloch P. The Oxford NOTECHS system: reliability and validity of a tool for measuring teamwork behaviour in the operating theatre. Qual Saf Health Care. 2009;18(2):104–8. 17. King HB, Battles J, Baker DP, Alonso A, Salas E, Webster J, Toomey L, Salisbury M. TeamSTEPPS: team strategies and tools to enhance performance and patient safety. In: Henriksen K, Battles JB, Keyes MA, et al., editors. Advances in patient Safety: new directions and alternative approaches, Performance and tools, vol. 3; 2008. http://www.ncbi.nlm.nih. gov/pubmed/21249942. 18. Reason J. Beyond the organisational accident: the need for “error wisdom” on the frontline. BMJ Qual Saf. 2004;13:ii28–33. 19. National Patient Safety Agency. Foresight training resource pack. 2008. https://webarchivenationalarchivesgovuk/20171030133314/http:// wwwnrlsnpsanhsuk/resources/patient-safety-topics/ human-factors-patient-safety-culture/?entryid45=59 840&p=2. Accessed 21 Oct 2019. 20. Taylor-Adams S, Vincent C. Systems analysis of clinical incidents: the London protocol. Clin Risk. 2004;10:211–20. 21. Queensland Health. Best practice guide to clinical incident management. 2014. p. 67. https://clinicalexcellence.qld.gov.au/sites/default/files/2018-01/clinicalincidentguide.pdf. Accessed 21 Oct 2019. 22. Rodriguez-Paz JM, Kennedy M, Salas E, Wu AW, Sexton JB, Hunt EA, Provonost PJ. Beyond “see one, do one, teach one”: toward a different training paradigm. BMJ Qual Saf. 2009;18:63–8. 23. Kotsis SV, Chung KC. Application of See One, Do One, Teach One Concept in Surgical Training. Plast Reconstr Surg. 2013;131(5):1194–1201. 24. Weller JM, Nestel D, et al. Simulation in clinical teaching and learning. Med J Aust. 2012;196(9):594. 25. Zwaan L, Len LTS, et al. The reliability and usability of the anesthesiologists’ non-technical skills (ANTS) system in simulation research. Adv Simul. 2016;1(18) https://doi.org/10.1186/ s41077-016-0013-2. 26. Endsley MR. Towards a theory of situation awareness in dynamic systems. Hum Factors. 1995;37(1):32–64. 27. Klein G. Naturalistic decision making. Hum Factors. 2008;50(3):456–60.
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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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360 implant versus intravitreal ant
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Part IV Healthcare Organization
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366 causes of safety incidents and
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368 • Human factors such as teamw
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370 access to the Emergency Room. F
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372 that many doctors simply choose
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374 E. Alti and A. Mereu Open Acces
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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 and 412: Non-technical Skills in Healthcare
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Page 433 and 434: Medication Safety Hooi Cheng Soon,
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Page 445 and 446: 31 Medication Safety quently when m
Page 447 and 448: 31 Medication Safety 31.5 Final Rec
Page 449 and 450: 31 Medication Safety 451 ity and im
Page 451 and 452: 31 Medication Safety 453 Open Acces
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Page 459 and 460: 462 32.4.2 The Usability Assessment
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Page 469 and 470: 472 S. Ushiro et al. Childbirth fac
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Page 473 and 474: 476 (c) (d) (e) (f) (g) (h) (i) (j)
Page 475 and 476: 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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