Perioperative Care Case Study Evolve

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The publication of To Err Is Human in the USA and An Organisation with a Memory in the UK more than a decade ago put patient safety firmly on the clinical and policy agenda. To date, however, progress in improving safety and outcomes of hospitalized patients has been slower than the authors of these reports had envisaged. Here, we first review and analyse some of the reasons for the lack of evident progress in improving patient safety across healthcare specialities. We then focus on what we believe is a critical part of the healthcare system that can contribute to safety but also to error—healthcare teams. Finally, we review team training interventions and tools available for the assessment and improvement of team performance and we offer recommendations based on the existing evidence-base that have potential to improve patient safety and outcomes in the coming decade.

Editor's key points

  • Human factors are major contributors to errors in healthcare that can impact patient safety.

  • Improvements in the safety and outcomes of hospitalized patients have been slower than expected.

  • Healthcare team-based approaches, including simulation, standardization, and training, could further improve patient safety.

In the past 10 years, healthcare has changed dramatically. Major reports have highlighted human error and adverse events that patients, particularly those admitted to hospitals, suffer—including the Institute of Medicine's (IoM) report To Err Is Human published in 1999 in the USA1 and the Department of Health's (DH) An Organisation with a Memory published in 2000 in the UK.2 These reports followed a number of pioneering retrospective studies in the USA, Australia, and the UK that documented average error rates of 10% in hospital admissions—that is, that one in 10 hospital inpatients was likely to suffer an error during hospital stay.3–5 These publications brought about a sharp focus on patient safety issues in healthcare.

As a result of this publicity and a growing body of scientific and medical literature, patient safety has become a permanent part of the health policy and wider political agenda. Numerous changes have since been advocated to improve patient safety, including mandating minimum nurse-to-patient ratios,6 reducing working hours of trainee/resident doctors,7 introduction of ‘care bundles’ that improve patient outcomes,8,9 introduction of safety checklists,10,11 and advances to the science of simulation and teamwork training.12–15 Significant funding has been spent to develop and promote such interventions and to produce the evidence-base, via large-scale primary studies, that would help make the case for the efficacy of interventions such as checklists10,11 and team training16 in improving care processes and patient outcomes.

Where are we now? Despite numerous studies, policy reports, and (literally) hundreds of interventions to improve patient safety, progress has overall been slower than initially envisaged. A recent large-scale study from the USA found that the rates of error have remained relatively constant over the past few years.17 Similar analyses from the UK have arrived at a mixed conclusion, with some safety indicators improving, others deteriorating, and yet others showing no change.18 Although a lot of effort has been put into improving the safety of hospitalized patients, one might argue that in some ways, the results have been less than impressive.

Our aim in the present article is three-fold. First, we review and analyse reasons for the lack of evident progress in improving patient safety across healthcare specialities. Secondly, we focus on what we believe is a critical part of the healthcare system that can contribute to safety but also to error—healthcare teams. Finally, we review team training interventions and tools currently available for the assessment and improvement of team performance and team skills that can be used in operating theatres and intensive care units (ICUs). We conclude with a number of recommendations for healthcare team improvement.

Is healthcare becoming safer?

Measurement concerns

Although the question of whether hospital-based care has become safer for patients is straightforward, it has become increasingly evident that the answer is complex—for many reasons.18 A first problem that we still face is that safety indicators are often not readily available. Hospital systems worldwide rely on a wide range of coding schemes for diseases, treatments, and complications. These are often non-standardized in their entries and hence very difficult to meaningfully compare across sites, countries, and often even across time.19 To add to the complexity, the concept of ‘patient safety indicators’ is rather novel; developing and validating indicators is a field of scientific enquiry within the patient safety discipline.19 A second concern is that large-scale safety reporting systems as a means to gauge levels of patient safety have their own limitations. Such systems became popular and many were implemented as a result of the IoM and DH reports—the UK's ‘National Reporting and Learning System’ (NRLS) was a direct recommendation of the report An Organisation with a Memory.20 First introduced in 2003, the NRLS database currently contains more than 6.5 million incidents (data publicly available at However, reporting has been voluntary, it has typically been carried out by nursing personnel without much physician involvement, and it has never captured the true incidence of errors; recent studies have shown that incident reporting captures ∼6% of errors found via retrospective review of the patient record.21 Reporting levels tend to increase when a ‘safety alert’ of some sort gets published—as the reporters become more sensitized to the specific topic of the alert. For these reasons, incident reporting appears to be a surrogate marker of safety culture—such that hospitals that report higher levels of incidents have higher levels of safety awareness and culture among their frontline personnel.22 The general public reading a ‘report card’ (available in the USA) evaluating a hospital with higher incident levels than its competitor hospitals might, however, think differently.

Implementation concerns

The efficacy of patient safety interventions depends heavily on the quality of their implementation (perhaps even more so than biomedical interventions, e.g. a new drug). An obvious example of this is the introduction of safety checklists.23 Transplanted into healthcare from other high-risk industries (most notably aviation), safety checklists are currently becoming increasingly popular. An ever-expanding evidence-base, including high-profile studies such as the Michigan Keystone ICU project,24 the WHO Surgical Safety Checklist international pilot evaluation,10 and the SURPASS checklist randomized controlled trial (RCT) in the Netherlands,11 suggests that introduction of a checklist can improve outcomes in many acute clinical areas. Checklists, however, are not a panacea. Social scientists and the Michigan research group have argued that the success story of the ‘simple checklist’ that seems to be making healthcare headlines is somewhat deceptive.25 A checklist is not more than a technical solution: if used properly, it ensures that certain things will be reviewed at certain times. If the underlying problem, however, involves poor attitudes and lack of a culture of safety then it is doubtful that any checklist will make a positive impact on safety. That the checklists are not a ‘cheap and cheerful’ solution for the publicly funded UK National Health Service (NHS) was revealed by the early experiences of using the WHO Checklist in a London teaching hospital.26 The use of the WHO Checklist was highly variable among its three constituent parts (SIGN IN, TIME OUT, SIGN OUT) and also over time. The research team observed the checklist being done only partially (e.g. SIGN OUT omitted), with key participants not present in the operating theatre (e.g. senior surgeon not present), or in a dismissive manner. Checklists are not unique in the complexity of their implementation—care bundles, performance monitoring and feedback, team training, and other interventions aimed at enhancing patient safety can all fail at the implementation stage. We argue, therefore, that this is an additional explanation for the lack of robust evidence for wide-scale safety improvements—if safety interventions are poorly implemented their potential for a positive impact on patient outcomes will be limited.23

Healthcare teams

Individual clinicians vs healthcare teams

Healthcare is a team sport; teams take care of patients.27,28 Healthcare teams operate in an environment characterized by acute stress, heavy workload, often high stakes decision-making (e.g. a laparotomy cannot be undone if later proven unnecessary) and very consequential errors.29 Individuals have limited capabilities. In his classic review of how human factors impact on adverse events, the psychologist Reason30 has suggested that human rather than technical failures represent the greatest threat to complex and potentially hazardous systems, including healthcare. When human limitations are combined with organizational and environmental complexity, ‘production pressures’ and the naturally occurring stress of managing very sick patients, human error becomes virtually inevitable.31,32 The following determinants have been shown to affect the quality of clinical performance within healthcare settings.

Individual healthcare providers' skills and competencies

Within interventional specialities, like anaesthesia and surgery, these are often split between ‘technical skills’ and ‘non-technical skills’.33–37 The former include the psychomotor dexterity and coordination that are required to carry out complex psychomotor tasks (e.g. to intubate a patient or successfully place an epidural catheter). The latter include the skills that allow a healthcare provider to work well as a member of a team (e.g. communication, leadership).

Teamworking and team effectiveness

As care is being delivered by teams, the quality and effectiveness of team communication,27,38 team monitoring/situation awareness,39 and team coordination40 are important—not just for safety but also from the perspective of efficiency.

Clinical environments

The hospital environment is often not conducive either to individualized work or to teamworking. Distractions and interruptions (e.g. during medication administration, during the induction, maintenance and emergence from anaesthesia, or during a surgical procedure) have been analysed in detail in the past few years and have been shown to contribute to the loss of concentration and deterioration of safety.41–45

Taken together these three determinants of good (or poor) performance and safety comprise what is known as a ‘Systems Approach’ to patient safety46–49—which recognizes that human operators are fallible and when under extreme pressure, errors will almost inevitably occur. Indeed, lapses and problems in one or more of these three categories have been consistently identified as ‘latent risk factors’ within healthcare units and organizations where errors subsequently occur.50

Teamwork and team performance

Patient safety is ‘predicated on trust, open communication, and effective interdisciplinary teamwork’.51 Teamwork can be defined as a ‘set of interrelated behaviours, actions, cognitions and attitudes that facilitate the required task work that must be completed’.52 There is a vast literature outside healthcare and increasingly within it on what makes teams work well together and be effective. Team communication and information sharing are critical for optimizing team performance.53 According to Baker and colleagues,54 to work together effectively team-members must possess specific knowledge, skills and attitudes such as the skill to monitor each other's performance and correct errors before they become adverse events or cause harm, knowledge of their own and team-mates' task responsibilities, and a positive disposition towards working in a team. Behaviours found in effective teams include team leadership, mutual performance monitoring, backup behaviour (i.e. mutual support), adaptability, communication, team orientation, and mutual trust.54 These behaviours have also been found relevant to operating theatre55 and ICU56 contexts. Moreover, an important cognitive characteristic of effective teams is that they have shared and accurate ‘mental models’—which means that the team-members hold an accurate and shared understanding of the task at hand, their equipment, and their team-mates—including who is responsible and able to carry out which task at what point in time.39,57 Thomas and colleagues58 conducted a qualitative assessment of teamwork and suggested that factors that influence the ability of a group of individuals to work together as a team include the following: Team effectiveness is in itself a key endpoint—the question is ‘what is an effective team’? Within the healthcare literature, this has sometimes been treated as a ‘black box’—the emphasis has traditionally been on patient outcomes and clinical processes because these endpoints are evidently relevant to patients and can also be assessed more objectively. However, simply stating, for instance, that a good theatre team is one whose patients always get antibiotics on time and deep venous thrombosis (DVT) prophylaxis before an operation masks a number of issues of relevance to how teams are assembled and developed—and also a range of team-related outcomes that are often ignored. Although necessary, objective clinical metrics of team effectiveness are not sufficient because they tell us little in terms of how to improve a team. From the perspective of team science, Hackman59 has analysed three critical aspects of a team's peformance:

  • Team-members’ characteristics: their personal skills and attributes, reputation, expertise.

  • Workplace factors: staffing levels, work organization, work environment.

  • Group influences: communication, behaviours, and inter-relationships within the team.

  • Whether or not the team accomplishes its goals: this reflects the examples above, that is, whether a theatre team ensures that antibiotics and DVT prophylaxis have been administered on time.

  • Team-member satisfaction with the team and commitment to team goals: this is a longitudinal team outcome, mostly neglected in healthcare teams. It refers to whether frontline staff are happy to be part of their team—which in turn can be linked to the morale of the team, a range of behaviours mentioned above (e.g. trust in each other, mutual support and back up, etc.), and also to team-members' turnover (as unhappy team-members are more likely to leave the team/organization when an opportunity arises).

  • The ability of the team to improve their team effectiveness over time: just like individuals, teams have learning curves. As with Olympic athletes, a team of experts that has just been put together does not necessarily make an expert team—teams develop their expertise over time, learn from their mistakes, and improve their processes and skills.

Team leadership

An important aspect of team performance is how it is led. Team leadership is a complex function—a recent review across industries proposed that it involves the three core activities of Leading (over years), Managing (over months), and Coaching (daily) (Table 1).

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