Latent Safety Threats and Countermeasures in the Operating Theater A National In Situ Simulation-Based Observational Study
Introduction: In situ simulation provides a valuable opportunity to identify latent safety
threats (LSTs) in real clinical environments. Using a national simulation program, we explored latent safety threats (LSTs) identified during in situ multidisciplinary simulation-based training in operating theaters in hospitals across New Zealand.
Method: Surgical simulations lasting between 15 and 45 minutes each were run as part
of a team training course delivered in 21 hospitals in New Zealand. After surgical in situ
simulations, instructors used a template to record identified LSTs in a postcourse report.
We analyzed these reports using the contributory factors framework from the London Protocol to categorize LSTs.
Results: Of 103 postcourse reports across 21 hospitals, 77 contained LSTs ranging across all factors in the London Protocol. Common threats included staff knowledge and skills in emergencies, team factors, factors related to task or technology, and work environment threats. Team factors were also commonly reported as protecting against adverse events, in particular, creating a shared mental model. Examples of actions taken to address threats included replacing or repairing faulty equipment, clarifying emergency processes, correcting written information, and staff training for clinical emergencies.
Conclusions: The pervasiveness of LSTs suggests that our results have widespread relevance to surgical departments throughout New Zealand and elsewhere and that collective solutionswould be valuable. In situ simulation is an effective mechanismboth for identifying threats to patient safety and to prompt initiatives for improvement, supporting the use of in situ simulation in the quality improvement cycle in healthcare.
(Sim Healthcare 00:00–00, 2021)
The flip side of speaking up: a new model to facilitate positive responses to speaking up in the operating theatre
Sustaining multidisciplinary team training in New Zealand hospitals: a qualitative study
of a national simulation-based initiative
Jennifer A Long, Tanisha Jowsey, Kaylene Henderson, Alan F Merry, Jennifer M Weller
AIM: Healthcare is delivered by teams, but the training of healthcare staff is commonly undertaken in professional silos. This study investigated local perspectives on the sustainability of NetworkZ, a New Zealand national simulation-based multi-disciplinary operating room team training programme.
METHOD: Local course instructors and managers were invited to participate in semi-structured interviews. Diffusion of innovations theory was utilised to frame deductive thematic analysis of interview data.
RESULTS: Twenty-seven people participated. Interviewees described valuing NetworkZ for its multidisciplinary orientation, in-situ delivery, scenario realism, relevance to teamwork and communication and potential for generalisability to other settings. Interviewees also identified NetworkZ as generating improvements in teamwork and crisis management. NetworkZ was described as complex, due to
multidisciplinary participation and the multiple roles and skillsets of instructors needed to run simulations smoothly, making the programme resource intensive to deliver.
CONCLUSION: NetworkZ is appreciated as a valuable and unique programme for developing important teamwork and communication skills. Its sustainability is dependent on adequate resourcing and funding.
Evaluation of the effect of multidisciplinary simulation-based team training on patients, staff and organisations: protocol for a stepped-wedge cluster mixed methods study of a national, insurer-funded initiative for surgical teams in New Zealand public hospitals
Weller, J. M., Long, J. A., Beaver, P., Cumin, D., Frampton, C., Garden, A., L, Moore, M. R., Webster, C. S., & Merry, A. F. (2020). Evaluation of the effect of multidisciplinary simulation-based team training on patients, staff and organisations: protocol for a stepped-wedge cluster mixed methods study of a national, insurer-funded initiative for surgical teams in New Zealand public hospitals. BMJ Open, 10, e032997.
Introduction: NetworkZ is a national, insurer-funded multidisciplinary simulation-based team-training programme for all New Zealand surgical teams. NetworkZ is delivered in situ, using full-body commercial simulators integrated with bespoke surgical models. Rolled out nationally over 4 years, the programme builds local capacity through instructor training and provision of simulation resources. We aim to improve surgical patient outcomes by improving teamwork through regular simulation-based multidisciplinary training in all New Zealand hospitals.
Methods and analysis: Our primary hypothesis is that surgical patient outcomes will improve following NetworkZ. Our secondary hypotheses are that teamwork processes will improve, and treatment injury claims will decline. In addition, we will explore factors that influence implementation and sustainability of NetworkZ and identify organisational changes following its introduction. The study uses a stepped-wedge cluster design. The intervention will roll out at yearly intervals to four cohorts of five District Health Boards. Allocation to cohort was purposive for year 1, and subsequently randomised. The primary outcome measure is Days Alive and Out of Hospital at 90 days using patient data from an existing national administrative database. Secondary outcomes measures will include analysis of postoperative complications and treatment injury claims, surveys of teamwork and safety culture, in-theatre observations and stakeholder interviews.
Ethics and dissemination: We believe this is the first surgical team training intervention to be implemented on a national scale, and a unique opportunity to evaluate a nation-wide team-training intervention for healthcare teams. By using a pre-existing large administrative data set, we have the potential to demonstrate a difference to surgical patient outcomes. This will be of interest to those working in the field of healthcare teamwork, quality improvement and patient safety. New Zealand Health and Disability Ethic Committee approval (#16/NTB/143).
Evaluation of the effect of multidisciplinary simulation-based team training on patients, staff and organisations: protocol for a stepped-wedge cluster mixed methods study of a national, insurer-funded initiative for surgical teams in New Zealand public [open in new window|view inline]
Towards a safer culture: implementing multidisciplinary simulation-based team training in New Zealand operating theatres, a framework analysis
Jowsey, T., Beaver, P., Long, J., Civil, I., Garden, A., Henderson, K., Merry, A., Skilton, C., Torrie, J., & Weller, J. (2019). Towards a safer culture: implementing multidisciplinary simulation-based team training in New Zealand operating theatres, a framework analysis. BMJ Open(9), e027122
Aim: NetworkZ is a simulation-based multidisciplinary team-training programme designed to enhance patient safety by improving communication and teamwork in operating theatres (OTs). In partnership with the Accident Compensation Corporation, its implementation across New Zealand (NZ) began in 2017. Our aim was to explore the experiences of staff – including the challenges they faced – in implementing NetworkZ in NZ hospitals, so that we could improve the processes necessary for subsequent implementation.
Method: We interviewed staff from five hospitals involved in the initial implementation of NetworkZ, using the Organising for Quality model as the framework for analysis. This model describes embedding successful quality improvement as a process of overcoming six universal challenges: structure, infrastructure, politics, culture, motivation and learning.
Results: Thirty-one people participated. Structural support within the hospital was considered essential to maintain staff enthusiasm, momentum and to embed the programme. The multidisciplinary, simulation-based approach to team training was deemed a fundamental infrastructure for learning, with participants especially valuing the realistic in situ simulations and educational support. Participants reported positive changes to the OT culture as a result of NetworkZ and this realisation motivated its implementation. In sites with good structural support, NetworkZ implementation proceeded quickly and participants reported rapid cultural change towards improved teamwork and communication in their OTs.
Conclusion: Implementation challenges exist and strategies to overcome these are informing future implementation of NetworkZ. Embedding the programme as business as usual across a nation requires significant and sustained support at all levels. However, the potential gains in patient safety and workplace culture from widespread multidisciplinary team training are substantial.
Can team training make surgery safer? Lessons for national implementation of a simulation-based programme
Jennifer Weller, Ian Civil, Jane Torrie, David Cumin, Alexander Garden, Arden Corter, Alan Merry. Can team training make surgery safer? Lessons for national implementation of a simulation-based programme. New Zealand Medical Journal. 2016; 129(1443): 9-17.
Aim: Unintended patient harm is a major contributor to poor outcomes for surgical patients and oftenreflects failures in teamwork. To address this we developed a MORSim intervention to improve teamwork in the operating room (OR) and piloted it with 20 OR teamsin two of the 20 District Health Boards in New Zealand prior to national implementation. In this study, we
describe the experience of those exposed to the intervention, challenges to implementing changes in clinical
practice and suggestions for successful implementation of the programme at a regional or national level.
Methods: We undertook semi-structured interviews of a stratified random sample of MORSim
participants 3–6 months after they attended the course. We explored their experiences of changes in
clinical practice following MORSim. Interviews were recorded, transcribed and analysed using a general
inductive approach to develop themes into which interview data were coded. Interviews continued to the
point of thematic saturation.
Results: Interviewees described adopting into practice many of the elements of the MORSim intervention
and reported positive experiences of change in communication, culture and collaboration. They described
sharing MORSim concepts with colleagues and using them in teaching and orientation of new staff. Reported
barriers to uptake included uninterested colleagues, limited team orientation, communication hierarchies,
insufficient numbers of staff exposed to MORSim and failure to prioritise time for team information sharing
such as pre-case briefings.
Conclusion: MORSim appears to have had lasting effects on reported attitudes and behaviours in clinical
practice consistent with more effective teamwork and communication. This study adds to the accumulating
body of evidence on the value of simulation-based team training and offers suggestions for implementing
widespread, regular team training for OR teams.
Improved scores for observed teamwork in the clinical environment following a multidisciplinary operating room simulation intervention
Weller J, Cumin D, Civil I, Torrie J, Garden A., et al. Improved scores for observed teamwork in the clinical environment following a multidisciplinary operating room simulation intervention. New Zealand Medical Journal. 2015; 129(1439): 60-67.
Aims: We ran a multidisciplinary operating room simulation intervention course for 20 complete
general surgical teams from two large metropolitan hospitals. Our goal was to improve teamwork and
communication in the operating room (OR). We hypothesised that scores for teamwork and communication
in the OR would improve back in the workplace following MORSim. We used an extended Behavioural
Marker Risk Index (BMRI) to measure teamwork and communication, because a relationship has previously
been documented between BMRI scores and surgical patient outcomes.
Methods: Trained observers scored general surgical teams in the OR at the two study hospitals before and
after MORSim , using the BMRI.
Results: Analysis of BMRI scores for the 224 general surgical cases before and 213 cases after MORSim
showed BMRI scores improved by more than 20% (0.41 v 0.32, p<0.001). Previous research suggests that
this improved teamwork score would translate into a clinically important reduction in complications and
mortality in surgical patients.
Conclusions: We demonstrated an improvement in scores for teamwork and communication in general
surgical ORs following our intervention. These results support the use of simulation-based multidisciplinary
team training for OR staff to promote better teamwork and communication, and potentially improve
outcomes for general surgical patients.
Multidisciplinary operating room simulation-based team training to reduce treatment errors: a feasibility study in New Zealand hospitals
Weller J, Cumin D, Torrie J, Boyd M, Civil I., et al. Multidisciplinary operating room simulation-based team training to reduce treatment errors: a feasibility study in New Zealand hospitals. New Zealand Medical Journal. 2015; 128(1418): 40-51.
Aims: Communication failures in healthcare are frequent and linked to adverse events and treatment errors. Simulation-based team training has been proposed to address this. We aimed to explore the feasibility of a simulation-based course for all members of the operating room (OR) team, and to evaluate its effectiveness.
Methods: Members of experienced OR teams were invited to participate in three simulated clinical events using an integrated surgical and anesthesia model. We collected information on costs, Behavioural Marker of Risk Index (BMRI) (a measure of team information sharing) and participants’ educational gains.
Results: We successfully recruited 20 full OR teams. Set up costs were NZ$50,000. Running costs per course were NZ$4,000, excluding staff. Most participants rated the course highly. BMRI improved significantly (P = 0.04) and thematic analysis identified educational gains for participants.
Conclusion: We demonstrated feasibility of multidisciplinary simulation-based training for surgeons, anesthetists, nurses and anaesthetic technicians. The course showed evidence of participant learning and we obtained useful information on cost. There is considerable potential to extend this type of team-based simulation to improve the performance of OR teams and increase safety for surgical patients.
Information transfer in multidisciplinary operating room teams: a simulation-based observational study
Cumin, D, Skilton C, & Weller J. Information transfer in multidisciplinary operating room teams: a simulation-based observational study. BMJ Quality & Safety. 2016; 0: 1-8. doi:10.1136/bmjqs-2015-005130
Background: Communication of clinically relevant information between members of the operating room (OR) team is critical for safe patient care. Formal communication processes, such as briefing, sign in and time out, are designed to promote this.
Aims: We investigated patterns of communication of clinically relevant information between OR staff in simulated surgical scenarios, to identify factors associated with effective information sharing. We focused on the influence of precase briefing, sign in and time out, which we defined as formal team communications.
Method: Twenty teams of six participated in two scenarios during a day-long course. Participants each received unique, clinically relevant items of information (information probes) prior to simulations and were tested post scenario on recall of the information in the probe. Using videos of the simulations, we coded each time an information probe was mentioned against a structured framework.
Results: Of the 145 instances where a probe was mentioned at least once, 75 (51.7%) were mentioned during a formal team communication. However, there were 89 instances of a possible 234 (38%) where a probe was never mentioned. Some team members were more likely to mention the information than others. When probes were mentioned during formal team communications, significantly more team members were attentive (1.4 vs 2.3; p<0.001), the information was significantly more likely to be recalled and the team was five times more likely (p=0.01) to recall the information than if the information was only mentioned outside of a formal communication.
Conclusion: While our study supports the value of formal team communications during precase briefing, sign in and time out in the Surgical Safety Checklist, our findings suggest suboptimal transmission of information between team members and unequal contributions of information by different professional groups.
A Systematic Review of Simulation for Multidisciplinary Team Training in Operating Rooms
Cumin D, Boyd M, Webster C, & Weller J. A Systematic Review of Simulation for Multidisciplinary Team Training in Operating Rooms. Society for Simulation in Healthcare. 2013; 8(3): 171-9.
Summary Statement: Current simulation training initiatives predominantly occur in uniprofessional silos and do little to integrate different disciplines working in the operating room (OR). The objective of this review was to determine the current status of work describing simulation for full OR multidisciplinary teams including barriers to conducting OR multidisciplinary team training and factors contributing to successful courses. We found a total of 18 articles from 10 research groups. Various scenarios and simulators were used, and training sessions were generally perceived as realistic and beneficial by participants despite rudimentary integration of surgical and anesthetic models. Measures of performance involved a variety of both technical and nontechnical ratings of the simulations. Challenges to conducting the simulations included recruitment, model realism, and financial costs. Future work should focus on how best to overcome the barriers to implementation of team training interventions for full OR teams, particularly on how to engage senior staff to aid recruitment.