not an expert team"
Learning objectives
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? Create an understanding of the relevance of NOTSSfor safe surgical practice.
? Discuss key non-technical skills in surgical context.
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? Illustrate how non-technical failures can lead to poor
clinical outcomes.
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Introduction? Globally, approximately 234m surgeries are done annually.
? This results in 7m complications and 1m deaths.
? 44,000-98,000 people die each year in US hospitals due to medical
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errors.
? 4.3% of mortality in surgical patients is due to technical issues.
? Rest of them are due to poor decision making.
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? Is technical competence enough for modern safe surgical practice?What are non-technical skil s?
? "Skills that allow surgeons to monitor the situation, make decisions,
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take a leadership role, communicate and co-ordinate in a team toachieve high levels of safety and efficiency."
? These skills are not incorporated explicitly in surgical training.
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? With increasing attention to patient safety this is the need of the hour.Categories in NOTSS
Categories in NOTSS
CATEGORY
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ELEMENTS
1. Situation Awareness
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?Gathering information? Understanding information
? Projecting and anticipating future state
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2. Decision Making
? Considering options
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? Selecting and communicating option? Implementing and reviewing decisions
3. Communication and Teamwork
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? Exchanging information
? Establishing a shared understanding
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? Co-ordinating team activities4. Leadership
? Setting and maintaining standards
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? Supporting others
? Coping with pressure
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1.Situation Awareness? Having dynamic awareness of the situation in the theatre/ward/OPD
based on collecting data from the environment; understanding what
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they mean, and thinking ahead about what may happen next.
1. Gathering information
2. Understanding information
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3. Projecting and anticipating future stateGathering information
Seeking information from the patient, team, displays, equipment.
1a) Gathering information
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? Pre-operative checks of patient notes, investigations and consent.
? Ensures that all relevant investigations (e.g. imaging) are available.
? Talks with anaesthetist regarding anaesthetic plan
? Optimises operating conditions before starting e.g. moves table,
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lights, AV equipment.
? Monitors ongoing blood loss.
? Asks anaesthetist for update.
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Understanding informationInterpreting the information gathered, and to identify the match or mismatch
between the situation and the expected state.
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1b) Understanding information? Act according to information gathered from investigation and
operative findings.
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? Reflect and discuss significance of information.
? Do not discard results that don't `fit the picture'.
Projecting and anticipating future state
Predicting what may happen in the near future as a result of possible actions,
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interventions or non-intervention.
1c) Projecting and anticipating future state
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? Plan operating list.? Communicate what equipment may be required during operation.
? Have a contingency plan (`plan B').
? Cite contemporary literature on anticipated clinical event.
? Do not operate beyond level of experience.
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? Overconfidence with no regard for what may go wrong is notacceptable
2) Decision Making
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? Diagnosing the situation and choosing an appropriate course ofaction.
1. Considering options
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2. Selecting and communicating option3. Implementing and reviewing decisions
Considering options
Discussing all available options to solve a problem. Weighing the threats and
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benefits of potential options.
2a) Considering options
? Recognise and articulate problems
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? Initiate a balanced discussion of options, pros and cons with teammembers
? Ask for opinion of other colleagues
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? Discuss published guidelinesSelecting and communicating
option
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Choosing a solution to a problem and letting all relevant personnel know thechosen option.
2b) Selecting and communicating option
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? Select an option and clearly communicate it to other team members.? Make provision for and communicate `plan B'.
? Explain why contingency plan has been adopted
? Do not shut down discussion on other treatment options.
? Do not stick to what you think is best.
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Implementing and reviewing
decisions
Undertaking the chosen course of action and continually reviewing its suitability in
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light of changes in the patient's condition.
2c) Implementing and reviewing decisions
? Implement decision confidently
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? Update the team on progress.? Reconsider plan in light of changes in patient condition or when
problem occurs.
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? Change to `plan B' in time if you realise `plan A' is not working.? Call for assistance if required.
? Do not rush due to perceived time constraints.
3) Communication and Teamwork
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? Skills for working in a team to ensure that the team has a shared
picture of the situation and can complete tasks effectively.
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1. Exchanging information2. Establishing a shared understanding
3. Co-ordinating team activities
Exchanging information
Giving and receiving knowledge and information in a timely manner
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3a) Exchanging information
? Talk about the progress of the operation/intervention.
? Listen to concerns of team members.
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? Communicate that operation is not going as planned.? Do not attempt to resolve problems alone.
? If you need help from assistant, make it clear what that assistant is
expected to do.
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Establishing a sharedunderstanding
3b) Establishing a shared understanding
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? Provide briefing and clarify objectives and goals before commencing
operation.
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? Ensure that the team understands the operative plan before starting.? Encourage input from all members of the team.
? Ensure relevant members of team are comfortable with decisions.
? Debrief team members after operation, discussing what went well
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and problems that occurred.Co-ordinating team activities
Working together with other team members to carry out cognitive and physical
activities in a simultaneous, collaborative manner.
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3c) Co-ordinating team activities
? Ask anaesthetist if it is OK to start operation.
? Proceed with operation after ensuring that equipments and team
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members are ready.
? Stop operating when asked to by anaesthetist or scrub nurse
4)Leadership
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? Leading the team and providing direction, demonstrating highstandards of clinical practice and care, and being considerate about
the needs of individual team members.
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1. Setting and maintaining standards
2. Supporting others
3. Coping with pressure
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Setting and maintainingstandards
Supporting safety and quality by adhering to acceptable principles of surgery,
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following codes of good clinical practice, and following theatre protocols.4a)Setting and maintaining standards
? Introduce your self to new or unfamiliar members of the theatre
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team.? Clearly follow theatre protocol.
? Ensure that all team members observe standards (e.g. sterile field).
? Do not show disrespect to the patient.
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Supporting others
Providing cognitive and emotional help to team members.
Judging different team members' abilities and tailoring one's style of leadership
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accordingly.
4b) Supporting others
? Modify behaviour according to trainee needs.
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? Provide constructive criticism to team members.? Never show hostility to other team members (e.g. making sarcastic
comments to juniors/ nurses)
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? Ensure delegation of tasks is appropriate.? Establish rapport with team members.
? Give credit for tasks performed well.
Coping with pressure
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Retaining a calm demeanour and emphasising to the team that things are undercontrol in a high-pressure situation.
4c) Coping with pressure
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? Remain calm under pressure.? Do not `Freeze' but make appropriate decision under pressure.
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? Take responsibility for the patient in emergency/ crisis situation? Do not blame everyone else for errors.
? Do not lose temper.
Conclusion
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? Modern surgical practice requires technical and non-technical skills,
evidence based practice, an emphasis on life long learning and
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monitoring of outcomes.? Research is now focussed on the mechanism by which lack of NTS
causes patient harm.
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? Being a good surgeon is more than just being a "good pair of hands"
Professionalism and personal values
? Integrity, respect for patient autonomy and choice, patient centred
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and compassionate care.
? Hamlin et al found that patients viewed respect for autonomy and
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communication skills as more important than technical skills.? Surgeons should offer care that is patient centred and holistic rather
than being disease focussed.
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