A study of airline disasters conducted between 1968 and 1976 revealed more than 60 accidents which involved problems in team coordination. Similar to aviation, 65-70% of all incidents and accidents in anesthesia are attributed in part to human error. Adverse outcomes occur in both domains despite satisfactory technical expertise on the part of the professionals involved. Up until now in anesthesia, training and selection have focused almost exclusively on individual skills since we know very little about the factors that determine effective team performance. Nevertheless, successful operating room team interaction can be crucial for safe patient outcome. The following case report describes a situation where interaction between a skilled team was suboptimal and could have resulted in disaster.
Case Report: A 40 year old male was undergoing an aortic valve replacement for aortic insufficiency. As the surgeon was incising the pericardium with the electrocautery device, the patients heart fibrillated. The abnormal rhythm was quickly diagnosed by the anesthesiologist who notified the surgeon who then called for the internal defibrillator paddles. The surgeon asked for the defibrillator to be set on 10 Joules and then gave a command for the nurse to discharge the paddles. The nurse did not understand the surgeon’s command to “shoot,” and did not discharge the paddles until the anesthesiologist instructed the nurse to “hit it,” which is the command usually used in this particular operating room for the nurse to discharge the defibrillator. This resident surgeon had not been acclimatized to the ‘language’ of this particular operating room and the members of the team were not communicating optimally during this crisis. Once the nurse understood the command, the patient was successfully defribrillated and the case proceeded uneventfully. The patient suffered no apparent effects from the brief arrest in the postoperative period.
What Makes a Team
Psychologists define a team as ‘a distinguishable set of two or more people who interact dynamically, interdependently and adaptively toward a common and valued goal, and have each been assigned specific roles or functions to perform.’ Imbedded in this definition is that task completion requires: (1) a dynamic exchange of information and resources among team members; (2) coordination of task activities; (3) constant adjustments to task demands; (4) some organizational structuring of team members. What makes teams different from mere groups of individuals is the fact that all teams share some form of interdependency between members. This definition obviously describes the operating room environment.
The ability of individuals to work together as a team is vitally important in many complex systems and the operating room is clearly no exception. Teams have obvious advantages over individuals in that they have a greater collective amount of knowledge and skill for problem-solving. Most important to team success is the interdependent nature of team dynamics since team members are able to pool information, share resources, and check errors in accomplishing a task. Poor team performance is often characterized by groups of individuals who lack interdependence or collective behavior of the team members.
In studies of teams, psychologists have categorized critical performance events into seven dimensions termed ‘critical team behaviors.’ The headings of these behaviors are as follows: communication, cooperation, team spirit and morale, giving suggestions or criticism, acceptance of suggestions or criticism, coordination, and adaptability. Sports teams exhibit excellent examples of both effective and ineffective team interaction. Individuals who perform well together as a team often display good communication, adaptability, coordination, team spirit and cooperation. Ineffective teams may have superior talent, but often do not fare as well as the “good’ teams because of the lack of these critical team behaviors.
From the patient safety perspective, the most critical time for optimal teamwork is during the planning of the anesthetic and during crisis situations. The preoperative period is a crucial time for optimization of patient status prior to surgical trespass. The surgeon and other consultant physicians should communicate their concerns to the anesthetist who should design an anesthetic plan that will optimize the patient’s chance for a good outcome.
Teamwork during crises is extremely important as exhibited by the case report. Surgeons are often preoccupied with the technical tasks of the surgical procedure and if problems are not communicated between the members of the team, adverse outcomes for the patient are more likely to ensue. Communications between anesthetist and surgeon should remain open at all times. If one member of the team is having a problem, other team members should be alerted and help in any way possible. For example, if the surgeon inadvertently cuts the inferior vena cava, the anesthetist and the nursing staff should perform the duties to which they are accustomed. For the anesthetist, this will involve support of the circulation and maintenance of oxygenation and ventilation. The nursing staff, under the direction of the anesthesiologist, should obtain help from outside resources to assist the team while the surgeon repairs the bleeding vessel.
Team interaction is studied extensively in other complex worlds (aviation, military, and perhaps most extensively in the space program). The operating room environment lends itself to the study and teaching of effective team interaction and should be a focus of future research for those interested in patient safety. Teamwork is currently being studied using videotape analysis in emergency departments (evaluating trauma teams) and in the operating room. These studies should help determine and evaluate the principles of teamwork that should be incorporated into our daily practice.
Finally, each member of the operating room team has his or her own unique contribution to add to patient care. By studying and understanding team dynamics, patient safety will be improved and job satisfaction likely enhanced.
Dr. Howard is a Clinical Instructor of Anesthesia at the Stanford University Medical Center and Staff Anesthesiologist at the Palo Alto Veterans Affairs Medical Center.