Publications

BACKGROUND:

Preventable intraoperative errors have the potential to lead to adverse events. Our objective was to build a conceptual model of the relationship between minute technical errors performed by the surgeon and adverse patient outcomes.

MATERIALS AND METHODS:

We used constructivist grounded theory methodology to build a model for the avoidance of technical errors. We used the Observational Clinical Human Reliability Assessment system, which categorizes granular, technical intraoperative errors, as our conceptual framework. We iteratively interviewed surgeons from multiple adult and pediatric surgical specialties, refined our semi-structured interview, and developed a conceptual model. Our model remained stable after interviewing 11 surgeons, and we reviewed it with earlier interviewed surgeons.

RESULTS:

Our conceptual model helps us understand how technical errors can be associated with adverse outcomes and is applicable to a broad range of surgical steps. Each technical error is defined by a unique improper technical motion that without a compensatory response, it may lead to 1 or more discreet adverse outcomes. Our model includes 5 primary defenses against an adverse outcome, including perfect technique, recognizing imperfect technique, adequately correcting imperfect technique, recognizing an adverse event, and adequately compensating for an adverse event. It includes multiple examples of compensating for a technical error, resulting in a near miss.

DISCUSSION:

Our conceptual model suggests that adverse patient outcomes can be related to minute technical deviations in surgical technique and provides a basis to study these preventable errors. Our model can also be used to develop intraoperative strategies to prevent these technical surgical errors.

Keywords: adverse events; adverse outcomes; medical education; patient safety; qualitative research; surgery; surgical errors.

BACKGROUND:

Our objective was to examine the influence of silence on team action in the operating room.

METHODS:

We conducted a constructed grounded theory study with semi-structured interviews with 25 interprofessional surgical team members. Using a framework of silence as communication and performance, transcripts were iteratively team-coded to develop themes and a conceptual model.

RESULTS:

OR silence is expressed verbally and nonverbally. Two contexts of silence were identified: homogenous as collective action, and disparate, as disengagement. Complex and dynamic, two primary themes emerged, Power that often shuts down communication, and Focus during critical moments. Five additional sub-themes included critical moments, respect, self-reflection, personal preference, and, bad mood.

CONCLUSION:

OR silence is not an absence of communication and requires a response. Whether homogenous through cohesiveness, or desperate as a solitary act, OR silence is a call to action. Examining silence as a part discourse has important implications on surgical team function.

OBJECTIVE:

The primary aim of this study was to use cognitive task analysis to expand the retropubic midurethral sling into smaller steps, reflecting a surgeon s internal thought processes during the surgery.

METHODS:

Two surgeons and a cognitive psychologist collaborated with expert urogynecologic surgeons in structured discussions and semistructured interviews, iteratively creating a list of clinical steps for the midurethral sling. They primarily considered 2 questions: (1) what action does the expert perform for this step, and (2) what information does the expert need to complete the step? We defined each additional piece of detail within a step as a microstep. The cognitive task analysis list was further reviewed by 4 external expert urogynecologic surgeons to obtain further detail. The process was repeated for every step until the maximum level of detail was reached. We used multiple methods to explore the relationship between microsteps and the cognitive load associated with various portions of the surgery.

RESULTS:

Cognitive task analysis expanded the midurethral sling from 23 to 197 microsteps. Steps with the greatest number of microsteps included retropubic advancement with the trocar (19 microsteps) and ventral advancement of the trocar through the skin (17 microsteps).

CONCLUSIONS:

The retropubic midurethral sling is a complex surgery with multiple microsteps embedded within in each step. Identification of these steps can lead to strategies to minimize cognitive load encouraging both efficacy and safety. Surgical training interventions and competency assessment can be developed based on this content.

CONTEXT:

In the high-stakes, time-critical environment of the operating room (OR), attendings and residents strive to complete safe, effective surgeries and ensure that learning occurs. Yet meaningful resident participation often receives less attention, and that impedes residents ability to learn and achieve autonomous operative practice. We need a new conceptual framework for understanding progression to autonomous practice that can guide both faculty and residents. Thus, we sought a new conceptualisation of intraoperative teaching and learning (IOT&L) through the lens of Eraut's notion of informal workplace learning and Billett's theory of relational interdependence between social and individual agency.

METHODS:

We viewed authentic examples of IOT&L in video and transcripts of live OR cases and interviews with participating attendings and residents. By systematically applying Eraut and Billet's theories to the transcripts and interviews, we developed concrete descriptions about how IOT&L occurs, categorised them into theory-based principles and derived a conceptualisation and related research ideas about IOT&L.

RESULTS:

Established workplace learning theories frame IOT&L as socially negotiated processes transpiring in distinct interdependent interactions between residents individual cognitive experiences and their OR social experiences that direct their learning. As the surgery unfolds, spontaneous events and the rules of surgery create opportunities for unplanned and informal learning. These authentic interrelated cognitive and social experiences are stimulated when residents reveal a learning need or attendings recognise a learning gap, and efforts ensue to bridge that gap. Through these minute distinct exchanges, labelled here as atomic IOT&L, residents gain crucial knowledge and skill.

CONCLUSION:

Framing authentic OR interactions between attendings and residents in terms of micro-relational interdependencies shows how granular teaching/learning exchanges yield high-value informal learning. To improve IOT&L, we must examine and change it at this fundamental level by using and testing this new theoretical conceptualisation. These insights produced ideas about IOT&L to test and research.

OBJECTIVES:

The objective of this study was to identify risk factors for having to return to the operating room for a second surgery after midurethral sling (MUS).

METHODS:

We used a case-control design. Cases return to operating room were a composite of 6 surgical complications or recurrent stress urinary incontinence because we believed that women would consider return to the operating room (OR) a similar MUS-related complication regardless of indication. Cases were obtained from Cerner Health Facts database, including 213 hospitals, using current procedural technology codes 57288 (repeat sling), 57287 (sling revision), and 53500 (urethrolysis) for procedures after index MUS. Controls no return to OR were randomly selected in 4:1 ratio from the remaining slings without these procedures. Multivariable regression analysis included all variables with P < 0.10 on univariable analysis.

RESULTS:

Between January 1, 2010, and December 31, 2016, 1247 patients returned to the OR of 17,953 patients who underwent initial MUS (6.9%). After adjusting for confounders, white race (OR, 1.47 [1.20-1.81]), lack of concomitant prolapse surgery (OR, 1.37 [1.18-1.59]), immunosuppressant drugs (OR, 1.27 [1.12-1.45]), and blood thinner use (OR, 1.38 [1.18-1.62]) significantly impacted the odds for returning to the OR. Anticholinergic use and smoking tobacco or marijuana, although significant on univariable analysis, were no longer significant after adjusting for confounders.

CONCLUSIONS: The rate of a second surgery after MUS using a composite outcome, over a 7-year period including multiple diagnoses, is 6.9%. White race, using immunosuppressant drugs, using blood thinners, and not having concomitant prolapse surgery are all risk factors for having second surgery after MUS.

BACKGROUND:

Surgical residents desire independent operating experience but recognize that attendings have a responsibility to keep cases as short as possible.

METHODS:

We analyzed video and interviews of attending surgeons related to more than 400 moments in which the resident was the primary operator. We examined these moments for themes related to timing and pace.

RESULTS:

Our surgeons encouraged the residents to speed up when patient safety could be jeopardized by the case moving too slowly. In contrast, they encouraged the residents to slow down when performing a crucial step or granting independence. Attending surgeons encouraged speed through economical language, by substituting physical actions for words, and through the use of Intelligent Cooperation. Conversely, they encouraged slowing down via just-in-time mini-lectures and by questioning the trainee.

CONCLUSIONS:

We present recommendations for safe teaching in the operating room while simultaneously maintaining overall surgical flow. Teaching residents to operate quickly can save time and is likely based on an automaticity in teaching. Slowing a resident down is vital for trainee skill development and patient safety.

Keywords: Pace; Patient safety; Qualitative research; Surgery; Surgical teaching; Videotape.

This Conversations Starter article presents a selected research abstract from the 2017 Association of American Medical Colleges Central Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of three experts who shared their thoughts stimulated by the study. These thoughts explore the value of examining intraoperative interactions among attending surgeons and residents for enhancing instructional scaffolding; entrustment decision making; and distinguishing teaching, learning, and performance in the workplace.

CONTEXT:

Observational research is increasingly being used in health professions education (HPE) research, yet it is often criticised for being prone to observer effects (also known as the Hawthorne Effect), defined as a research participant s altered behaviour in response to being observed. This article explores this concern.

METHODS:

First, this article briefly reviews the initial Hawthorne studies and the original formulation of the Hawthorne Effect, before turning to contemporary studies of the Hawthorne Effect in HPE and beyond. Second, using data from two observational studies (in the operating theatre and in the intensive care unit), this article investigates the Hawthorne Effect in HPE.

RESULTS:

Evidence of a Hawthorne Effect is scant, and amounts to little more than a good story. This is surprising given the foundational nature of the Hawthorne Studies in the social sciences and the prevalence of our concern with observer effects in HPE research. Moreover, the multiple and inconsistent uses of the Hawthorne Effect have left researchers without a coherent and helpful understanding of research participants responses to observation. The authors HPE research illustrates the complexity of observer effects in HPE, suggests that significant alteration of behaviour is unlikely in many research contexts, and shows how sustained contact with participants over time improves the quality of data collection.

CONCLUSION:

This article thus concludes with three recommendations: that researchers, editors and reviewers in the HPE community use the phrase participant reactivity when considering the participant, observer and research question triad; that researchers invest in interpersonal relationships at their study site to mitigate the effects of altered behaviour; and that researchers use theory to make sense of participants altered behaviour and use it as a window into the social world. The term participant reactivity better reflects current scientific understandings of the research process and highlights the cognitive work required of participants to alter their behaviour when observed. Perhaps the most important lesson to be learned from the original Hawthorne experiments is the power of a good story (Levitt & List, 2011).