Medida de la acomodación con estímulos mono y policromáticos

patient safety

Morris Gordon, College of Health and Social Care, University of Salford, Lancashire, UK

SUMMARY

Background:Patient safety is an increasingly recognised issue in health care. Systems-based and organisational methods of quality improvement, as well as educa- tion focusing on key clinical areas, are common, but there are few reports of educational inter- ventions that focus on non-tech- nical skills to address human factor sources of error. A flexible model for non-technical skills training for health care profes- sionals has been designed based on the best available evidence,

and with sound theoretical foun- dations.

Context: Educational sessions to improve non-technical skills in health care have been described before. The descriptions lack the details to allow educators to rep- licate and innovate further.

Innovation: A non-technical skills training course that can be delivered as either a half- or full- day intervention has been de- signed and delivered to a number of mixed groups of undergraduate medical students and doctors in postgraduate training. Participant

satisfaction has been high and patient safety attitudes have im- proved post-intervention.

Implications:This non-technical skills educational intervention has been built on a sound evidence base, and is described so as to facilitate replication and dissemination. With the key themes laid out, clinical educa- tors will be able to build inter- ventions focused on numerous clinical issues that pay attention to human factor contributors to safety.

There are few reports of educational interventions that focus on non-technical skills to address human factor sources of error

The broader

role

PaƟent safety educaƟon

CommunicaƟon

- STOP the line phrase - Check back - Call out Team working - Role clarity - Team briefing - Hierarchal communicaƟon - Shared mental model Error awareness - Lessons from outside health care

- CriƟcal incident analysis - Error feedback and

discussion Systems and technology - Checklists - Mnemonics (SBAR) - Man / Machine interface

Figure 1.Thematic areas and examples of techniques for enhanced safety

INTRODUCTION

T

he scale of the patient safety problem entered the public and professional conscious- ness in 1999, with the Institute of Medicine’s reportTo Err is Hu- man.1In 2000, the UK Depart- ment of Health responded with a report outlining the need for a systems-based human factor ap- proach to help manage risk in health care.2This was in line with thinking from a leading psychol- ogist in the field who proposed the now ubiquitous Swiss cheese model of error.3This model views human error as inevitable, and suggests that interventions should focus on barriers to pre- vent such human error causing harm. Despite strategies including audit, risk management, organi- sational safety culture change and new technology, errors still occur with alarming frequency.4

Non-technical skills describe the personal attributes of a pro- fessional that contribute to error. As such, they are not directly addressed in a systematic ap- proach to human factor safety improvement. Extensive work in high-stakes industries as early as the 1970s demonstrated that improving safety must also ad- dress the non-technical skills that lead to human error.5The airline industry recognised that many crashes were the result of failures in these non-technical skills, including interpersonal communi- cation, decision making and leadership.6Teaching programmes were designed to enhance skills, and are now used globally, but published works translating such methods into health care are sparse at best.7,8

CONTEXT

A systematic review of non-tech- nical skill patient safety educa- tion found that although a number of interventions have been used, based on the afore- mentioned airline crew resource

management, a key problem is a lack of descriptions of the inter- ventions and their theoretical underpinning.7As such, there is little published work that clinical teachers could replicate or use to guide their own design in this key area. Even the WHO patient safety curriculum fails to offer clarity in its theoretical discussions and pedagogical guidance on non- technical skills training.9

The systematic review of non- technical skills interventions in health care also reports a qualita- tive analysis of existing published interventions.7This identifies key content and teaching methods that should be used to construct an effective non-technical skills training course for health care professionals, with appropriate theoretical underpinning. This has been used to design such an intervention, and is presented to allow local non-technical skills patient safety educational inno- vation, as well as the replication of this intervention.

INNOVATION

Theoretical underpinning

Several themes were used to con- struct the course (Figure 1), each underpinned by key theoretical constructs. The theme of systems and technology is related to an economic theory of coordination costs. This describes how increasingly complex organisa- tions are subject to ever-increas- ing costs (either financial or time) in order to achieve effective management. This requires sys- tems to ensure safety, particularly at the human–system interface. Error awareness is related to agency theory. This social science theory describes how in settings of discontinuity, such as is often found in task-based working, the professional begins to think of ‘the patient’ rather than ‘my patient’. When this occurs, there is a potential to shirk professional responsibility, causing human er- ror. It has been proposed that highlighting sources of error in a way that is relevant to the task or

Non-technical skills … are not directly addressed in a systematic approach to human factor safety improvement

environment of professionals can challenge the ‘agency problem’.10

A psychological theory of egocentric heuristics describes how those giving information greatly overestimate their ability to do so, and highlights the key role of communication in safety. Additionally, social science theo- ries concerning diffusion of responsibility, which can lead to dysfunctional collaborative work- ing, highlight the role of methods to support team working. Finally, concepts such as the three-bucket model support the role of risk assessment in decision making.11 This theory views the risk in any situation from the professional’s perspective, and asks them to consider how full each of their buckets is (Figure 2). The buckets describe the risks associated with the ‘task’, the ‘context’ and the ‘self’. By considering this when taking on any new activity, pro- fessionals can learn to actively risk-assess and gain situational awareness in order to enhance safety.

Course participants

This course has been run with between 12 and 16 participants, consisting of a mixture of under- graduates, recent medical gradu- ates and specialty trainees. It has been run as a full- or half-day course, with the same overall structure.

Required resources

The course has been designed with minimal requirements, and can be run in a room equipped

with a PC with a projector or large monitor. The course has been run with one facilitator.

Teaching intervention

Figure 1 shows the concepts and techniques that are taught in relation to each of the theoreti- cally relevant themes identified for the course. The learning out- comes for the day are presented in Box 1, and the structure of a 1- day course is shown in Table 1, with a description of each of the activities.

Human factors as a source of error

Five-minute videos depicting ma- jor adverse events outside of health care (i.s. air, space and sea) were presented. In small groups, participants consider what caused the error, how could it be prevented, and how this relates to health care. This prompts a group discussion sur- rounding non-technical skill hu- man errors in health care, usually grounded in personal experience, in each of the course theme areas. The session finishes with a short

lecture discussing human factors and non-technical skills in health care.

Non-technical skill critical incident analysis

Anonymous participant incidents are analysed in small groups. Using a framework they consider the non-technical skill and hu- man factor system errors that occurred in each case, and how these could have been averted from the professional’s perspec- tive, by considering decisions at ‘switch points’. This activity reinforces the view that human error is not inevitable, and that enhancing their non-technical skills not only positively impacts their own behaviour, but also that of their colleagues, who may benefit from enhanced situa- tional awareness.

Enhancing safety

Short lectures with supporting handouts on each of the theme areas are delivered, covering a number of crew resource manage- ment improvement techniques (Figure 1). Participants complete exercises including the prepara- tion of a team briefing for an emergency incident, the handover of care using a system such as SBAR (situation, background, assessment and recommendation) and analysis of cases using the three-bucket model for risk assessment.

Discussing error with patients

A short discussion is facilitated regarding difficulties in giving

Figure 2. The three-buckets model for risk assessment. Adapted by permission from BMJ Publishing Group Limited. Quality and Safety in Health Care.Reason J.2004;13:suppl 2 ii28–ii33

Box 1. Learning outcomes for the non-technical skills patient safety course

•Gain insight into the role of non-technical skills in human factor causes of major adverse events outside health care.

•Discuss how such non-technical skills contribute to error within your own workplace.

•Review key skills to enhance safety practice through improved non- technical skills in each of the identified problem areas.

•Apply these non-technical skills in practical exercises related to key patient-safety issues, including prescribing, emergency planning and handover of care.

This activity reinforces the view that human error is not inevitable

feedback to patients when human errors occur, and the role of an open culture for adverse events in health care. Participants complete a role-play discussing a medica- tion error. An example scenario is shown in Box 2.

Large group exercises

Simulated team meetings are run in two large groups. The first group conduct a large handover meeting. The second group prepare for a difficult obstetric emergency. Par- ticipants are expected to integrate the different skill elements to facilitate safe practice and exhibit an enhanced ability to assess sit- uational error-provoking factors and address the risk that these pose to safety. Several participants act as observers and make notes in

each of the skill areas to feedback to their peers.

Evaluation

The local research and develop- ment department were contacted, and confirmed that they classified this as educational evaluation. As such, they did not require any formal ethical approval for anon- ymous data to be collected.

The course has been run on several occasions, with adapta- tions to the specific audience as needed. Feedback has been positive from participants of all backgrounds and levels of experience. Likert ratings for content, relevance, interactivity and enjoyment were positive (with mean ratings of 9⁄10 for

all areas). All (100%) participants reported that they felt more capable at spotting sources of human error after the session. Free-text responses identified the varied range of activities used and interactive styles of the course as positive. For future courses, it was suggested that some further pre-course material would be helpful to better frame the day and prepare the participants.

For one of the most recent half-day courses, the Attitudes to Patient Safety Questionnaire-II patient safety questionnaire was completed before and after the intervention. Patient safety atti- tudes improved significantly post intervention (with mean scores of Table 1. Course structure and relevant themes

Time* Session

Content and teaching

techniques Theme

09:30 Introduction Icebreaker, aims, objectives

09:45 Human factors as a source of error

Video scenarios from outside health care, group work, short lecture

Error awareness, situational awareness and risk assessment 11:00 Break and refreshments 11:15 Critical incident analysis and pro-active risk analysis

Small group analysis of anonymous participant cases

Error awareness, situational awareness and risk assessment – situated cognition 12:00 Techniques to enhance safety practice Communication, teamworking, practise scenarios using techniques Communication, teamworking 12:45 Lunch 13:30 Techniques to enhance safety practice (continued) Situational awareness, systems and technology, practise scenarios using techniques

Systems, situational awareness

14:30 Discussing

error with patients

Short review and practise in pairs

Communication

15:00 Break and refreshments

15:15 Group scenarios Each group to attempt applying techniques in two scenarios: handover; preparing for an emergency Simulation – situated cognition

16:00 Debrief and summary

*Using 24 hour clock format.

Participants reported that they felt more capable at spotting sources of human error after the session

134 before and 142 after; p = 0.026).

IMPLICATIONS

There have been numerous reports of educational interventions to enhance patient safety.7Addi- tionally, many clinical educators will have witnessed or been part of local innovation in this area. However, this report has set out to innovate by describing an intervention focused on the of- ten-confused area of non-techni- cal skills improvement. Although many of the elements are not revolutionary, it is hoped that the integration of these themes into a single package, with relevant theoretical underpinning, will

allow readers to introduce similar courses locally.

Many of the themes used within the course could form the basis of education on specific safety issues, such as prescribing, handover of care and resuscita- tion training. Although the focus of such education will often be on specific knowledge and skills, the addition of content that could enhance non-technical skills should become routine, as indeed all health care training can be patient safety training.

In considering the work pre- sented, a number of limitations must be taken into account. Although the intervention has

been run a number of times in different settings, it has been facilitated by the author on all occasions. How easily such inter- ventions can be replicated, how well materials can be disseminated for local instruction and whether these issues impact the interven- tion, remain unclear. Additionally, evaluation has mainly focused on qualitative comments and satis- faction outcomes. Finally, the full course has only been delivered to doctors so far, and so it is difficult to comment on its use for the wider health care team, despite its generic design.

Further work should consider the possibility of investigating different outcomes. Whichever investigative technique is chosen when assessing such outcomes, it should be robustly used and well described on publication. Addi- tionally, the use of this course for other professionals or in multi- professional teams should be investigated. Finally, consider- ation should be made as to the possibility of assessing whether such interventions can impact on patient outcomes and rates of adverse events.

CONCLUSION

This non-technical skill educa- tional intervention has been built on a sound evidence base, and has been described in order to facili- tate replication and dissemina- tion. With the key themes laid out, clinical educators will be able to build interventions focused on numerous clinical issues that pay attention to human factor con- tributors to safety. Future re- search should look to consider outcomes such as workplace behaviour change and patient adverse events, as well as refining or amending the conceptual ele- ments presented.

REFERENCES

1. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.

Box 2. Example scenario for participants to complete in groups of three

Communicating about an adverse event scenario

Instructions for doctor

Setting – paediatric intensive care unit (PICU) Time – 23:00

You have been asked to speak to a patient’s parent. Baby Thomas is currently ventilated for severe septicaemia with respiratory failure. He required a bolus of saline earlier in the day.

At handover, the nurses found a bag of IV metronidazole next to his bed. He is not on this medication, but when they aspirated, it became apparent that the volume missing is equal to the bolus given, and the consultant has presumed that as this bag looks similar to a bag of saline a bolus of met- ronidazole amounting to a 10-fold overdose has been given. Toxbase has been consulted and the medication is generally safe in overdose. Your task is to explain this incident to the parent.

Instructions for parent

When this case is discussed with you, try and stay in character and act as you may do in real life, asking appropriate questions.

Instructions for observers

There are several key elements to look for within this scenario: •Apologise (not personally, but for the whole team)

•Explain what happened •Discuss any risks •Describe actions

•Discuss incident reporting and analysis of this data •Offer complaints procedure

•Ask if they have any questions •Explain again and apologise again All health care

training can be patient safety training

2. Department of Health.An organisa- tion with a memory. London: Department of Health; 2000. 3. Reason J. Human error: models and

management.BMJ2000;320:768– 770.

4. National Patient Safety Agency. Quarterly daily summaries. Available at http://www.nrls.npsa.nhs.uk/re- sources/collections/quarterly-data- summaries. Accessed on 14 Febru- ary 2012.

5. Lerner S, Magrane D, Friedman E. Teaching teamwork in medical edu- cation.Mt Sinai J Med2009;76:318– 329.

6. Weiner EL, Nagel D.Human Factors in Aviation. New York: Academic Press; 1988.

7. Gordon M, Darbyshire D, Baker P. Education to enhance non-technical skills in health care professionals: A systematic review.Med Educ 2013; in press.

8. Ross S, Loke YK. Do educational interventions improve prescribing by medical students and junior doc- tors? A systematic review. Br J Clin Pharmacol2009;67: 662–670.

9. World Health Organization.WHO Pa- tient Safety Curriculum Guide for

Medical Schools. Geneva: World Health Organization; 2009. 10. Arora V, Johnson J, Lovinger D,

Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis.Qual Saf Health Care 2005;14:401–407.

11. Reason J. Beyond the organisational accident: the need for ‘error wisdom’ on the frontline.Qual Saf Health - Care2004;13:suppl 2:ii28–ii33.

Corresponding author’s contact details: Dr Morris Gordon, College of Health and Social Care, University of Salford, Salford, UK. E-mail: [email protected]

Funding:None.

Conflict of interest:None.

Ethical approval:Not required. doi: 10.1111/j.1743-498X.2012.00640.x Clinical educators will be able to build interventions that pay attention to human factor contributors to safety

ISSN: 2146-8354 J Contemp Med Edu 2013; 1(2): 77-82

Journal of Contemporary

In document Estudio de Fenómenos Dinámicos de la Óptica del Ojo Humano (página 123-145)