The next top tip for safer surgery that I'd like to talk you through is non-technical skills. Non-technical skills have been found to be responsible for causing adverse and unexpected outcomes in veterinary practise. In this session, we find out what non-technical skills are needed for safe and effective care, and we consider what steps can be put in place to reduce the chance of errors occurring.
Non-technical skills are the cognitive and social skills that complement technical skills to achieve safe and efficient practise. Non-technical skills are the cognitive, including situation awareness, task management and decision making, social, including leadership, teamwork and communication, and personal resource skills, including stress and fatigue management. They're important for safe and effective task performance.
Failures in non-technical skills have contributed to many dramatic accidents in recent history, such as the Piper Alpha oil platform disaster in the North Sea that suffered a fatal series of explosions, the Tenerife air disaster where two planes collided, resulting in mass loss of life. The Hillsborough football disaster, wrong site surgeries, and chemotherapy overdoses. And despite having been studied extensively in other high risk industries such as aviation and healthcare, researchers have only recently begun to investigate the non-technical skills important in veterinary practise.
In 2015, Catherine Oxerby found that deficiencies in non-technical skills, communication, teamwork and leadership were responsible for causing errors. She found that 51% of errors were primarily caused by cognitive limitations, with only 14% being due to a lack of technical skill or knowledge, and less than 1% due to inadequate care. The non-technical skills, generally regarded as the seven basic non-technical skills, imported for safe and efficient performance in the range of high high risk working settings from industry healthcare, military and emergency services, are situational awareness, decision making, communication, teamwork, leadership, and managing stress and coping with fatigue.
We've already identified the research that supports the fact that leadership, communication, teamwork are responsible for error. And as the research develops, this is further supported. Therefore, we must realise that to perform at our best, we must understand and train non-technical skills alongside our clinical skills and knowledge.
The first non-technical skill that I wanted to talk to you about is situational awareness. We often think of this as being able to think ahead of the surgeon. It's the perception of elements in the environment, within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future.
Situation awareness comes at 3 levels. The first is gathering information. So if we're performing in the role of the surgical nurse, this is listening, watching, and picking up on nonverbal clues that the surgeon may may give us.
Level 2 is interpreting the gathered information. Again, in the surgical nursing setting, we know that this is understanding the procedure and what equipment is required. And then level 3 is anticipating future states.
Being able to anticipate the surgeon's next move and being prepared with the instrumentation that we need. A loss of situation awareness can result in serious compromise to patient safety if it's not recognised by either the individual or the clinical team. And we know that there's several red flags that we need to be aware of, that if we notice these red flags, we need to stop and make sure that we gain situational awareness.
I'm sure many of you have heard of the story of Elaine Brobley, a lady who was admitted to hospital for routine sinus surgery, and whose airway closed and became blocked after her, her, her induction, and they were unable to place an ET tube. We know that some of these red flags occurred in her in her story. We know that at the anaesthetists who were highly skilled and experienced, became fixated on the single task of the exclusion of all else.
They became fixated on placing an endos kill tube because they knew that that was how that they were going to save her life. They failed to adhere to accepted practise. There was a protocol called can't intubate, can't ventilate, designed especially for this scenario.
But because they were so fixated on a single task, they didn't adhere to the accepted protocol. They didn't respond to warning signs such as a low pulse oximetry. And they failed to communicate effectively with their team.
There was confusion or uncertainty over what the best course of action would be. Also know Other red flags, that were not found in this case exist. We know that if there's an unresolved discrepancy between two sources of information, we need to stop and clarify it.
If our consent form says it's the right leg, but our surgical request form says the left leg, we need to go back and check which leg needs to be operated on. We know that if people start to use leading questions such as this is Fluffy Smith, isn't it? Or we are operating on the right leg, aren't we?
We need to stop and make sure that we have situational awareness. We also know that sometimes if something doesn't feel right, we need to listen to that feeling because sometimes it can mean that we've lost situation awareness and we need to reevaluate our actions. The next non-technical skill I want to talk about briefly is decision making.
Automatic decision making can be absolutely life-saving. We make approximately 35,000 decisions per day. And when we're an expert in what we're doing, we don't really think about how we make them.
An example of this is when you're driving. If you remember when you were learning to drive, you had to make a lot of effort to mirror, signal and manoeuvre. But when you become experienced, you realise that you just do these things intuitively and automatically.
Significant research has been done for us to enable us to understand decision making. And Gary Klein studied people working in high risk areas. He observed a fire chief at the scene of a house fire one day.
The team were wearing breathing apparatus and had gone into the smoke-filled building to check for trapped victims. Standing inside the building, the fire chief suddenly made the call for everyone to evacuate the building. Shortly after the last Mark Farman left the building, it erupted into flame and collapsed.
When Klein, the researcher, asked the chief how he had made that decision, he said he didn't know. It just seemed the right thing to do at that time. It took Klein another fortnight to establish that the chief had had noticed that the floor was sticky.
And Klein asked him had he ever seen this happen before? He said no, but a colleague had told him it had happened in another building and how the seat of the fire in the basement, the floor was starting to melt just prior to collapsing. I'm sure we can all consider times when we've been in this situation, when something hasn't felt right, and we've acted more on instinct than than actual reason.
So there are two types of decision making, automatic, type 1 decision making, which is all about recognition, pattern matching from previous experience. And it happens subconsciously, and when you have, you're an expert, you have more patterns to match and therefore you do it quickly. Type 2 decision making is conscious, it's deliberate.
It takes more time. And sometimes if we haven't had experience in this area, or we force ourselves to take a step back and to consider our options, this is the type of decision making that we would use. With time available, we can use this second type of decision making.
And we can fall back on a, a structure to help us make conscious decisions. We know that in the story of Sully, who had to land his aeroplane on the Hudson River, he used an an acronym such as Dodar to help diagnose the problem, consider his options. Decide how they should best proceed.
Assign different duties to different members of the team, and then review whether this was the best course of action. Without time available, however, we need to step back and fall back on our training, the briefings and huddles and pre-briefs, as we've already mentioned in this series, what if scenarios, mental rehearsal, experience, and simulations. And all of those things are really important, practise for making good decisions in automatic, environments.
Communication is the next non-technical skill that I want to mention. And please don't switch off. This is not just about how to talk to clients nicely.
It's about this technical scientific basis behind safe and effective communication in high risk industries or teams. And there's a few things that we need to consider about communication. We've already established that communication is the cause of 60 to 70% of preventable hospital deaths in healthcare, and therefore understand its importance.
We've also touched upon how patient safety briefings can be used. We can also use handover tools, checklists and care bundles to reduce the likelihood of error. We need to remember that written communication is the least rich way of transferring information, whilst the most rich way of transferring information is face to face communication.
Good communication perioperatively with not only the team but also the patient's owners is essential to reduce postoperative complications. However, we need to remember the fact that we can only remember 7 things at a time. So we need to consider that both verbal and nonverbal methods need to be used.
Taking the time to explain to an owner how they should care for their pet when they've been discharged should be backed up with written information on what they should do. So they can take that list home and refer to it when they get there. The next non-technical skill that I want to mention is teamwork.
Catherine Oxerby also found that teamwork influenced errors. And we need to consider that there are 5 key ingredients required to create a high performing team. The first is psychological safety.
The understanding that team members can raise their concerns, admit their mistakes or their errors, without the fear of retribution. We need to consider dependability, we need to be dependent on our other members of our team. We need to understand our roles and responsibilities.
And we need to make sure that we have meaning meaning and purpose within our roles and know that we're making a difference. The single most important thing to improve non-technical skills in the operating room has been found to be that knowing each other's names, their first names. And knowing and recognising team members by name associate is associated with increased trust, work engagement and clinical improvement.
Studies have shown that knowing the names of other team members greatly improves prevention of adverse outcomes. And the theatre challenge, designed by Rob Rob Hackett, which involves having your name printed on your theatre cap, led to an increased propensity to speak up from 45 to 85%. The next Non-technical skill that I want to talk through is leadership.
Leadership was also found to influence error. And whether we're the leader of a checklist or the person discovering and leading a crash situation, it's important to understand a few things about leadership. We know that effective team leaders are appropriately assertive.
They communicate task responsibilities. They balance responsibility with situational leadership. They involve all of their resources.
They communicate their expected normals, establish authority, and most of all, model or appropriate behaviour. We know that it's, it's less about the who and more about the how. The last but by no means least non-technical skill I want to talk to you about is managing stress and coping with fatigue.
Something that's so, so important within our clinical domains at the moment. It might be really difficult to practise and simulate stress and fatigue, but by understanding the symptoms and effects of both, we can learn strategies to enable better communication and therefore appropriate understanding and resolution. We've already mentioned Halt and the importance of taking breaks.
We need to ensure that people know that taking breaks is not a sign of weakness but essential for patient safety. So in this section, we've looked at the non-technical skills and how by implementing tools surrounding those skills, we can reduce, reduce error and increase patient safety.