Patient, Procedure, People (PPP): recognising and responding to intraoperative critical events

Abstract

Intraoperative critical events are rarely experienced by individual surgeons but are commonly experienced at a workforce level. Finding unfamiliar or unexpected pathology, anatomy, haemorrhage or an iatrogenic organ or structure injury cannot be completely eliminated in the complex surgical environment. It is vital that an appropriate, safe response to these infrequent events takes place to prevent possible further harm to patients. This paper introduces ‘Patient, Procedure, People’, a tool adapted from aviation threat and error management (TEM) training. It allows surgical teams to improve situational awareness (SA), communicate effectively, flatten team hierarchy gradients and improve decision-making before responding to critical events. We review factors contributing to poor decision-making, with resulting errors. These include loss of SA (tunnel vision), acute stress reactions (fight–flight or freeze–hide) and limbic hijacking (surprise and startle events). Events may cause workload to increase beyond cognitive capacity, further exacerbating the situation. After completing initial actions to achieve a temporary ‘place of safety’, surgical teams may use the tool to effectively manage threat or mitigate error. Aviation is a high-reliability organisation that has pioneered human factors research and training. Airline pilots undergo regular simulated emergencies assessment, including mandatory human factors assessment. Although the complexities of the operating theatre do not currently lend themselves to high-fidelity simulation as in aviation, valuable transferrable lessons can be learnt from aviation’s approach to TEM.

Applying human factors to improve patient safety, morale and team working for oral pathology and medicine specialists

“…We have recently published on the use of a PPP (patient, procedure, people) mini-brief to help in such situations 4 and actively teach colleagues to look out for each other and challenge in an open and non-confrontational way, when something does not seem right.…”

“…For this reason, when someone is stressed or angry we recommend pausing before speaking and allowing higher cognitive functions to catch up. 4 A useful pneumonic to remember is called HALT (= stop) and it brings all these factors together (Hungry, Anxious/Angry, Late or lonely, Tired). So please stop if it is safe to do, stop the task in hand and take a few minutes to improve your personal performance.…”

“…With colleagues looking out for each other, when something does not seem quite as it should, is good practice to stop, regroup and make sure things are going as planned. 4,8…”

“…For example, a difficult surgical procedure such as a complex neck dissection, added with additional stress (such as an operating list running late, or an inexperienced team), on a background of pre‐existing tiredness can all potentially align and lead to a serious error or mistake The value of taking short breaks potentially just a few minutes can make a difference and especially to confirm clinical decisions or challenge an action of a colleague is not only useful, but also may prevent an error. We have recently published on the use of a PPP (patient, procedure, people) mini‐brief to help in such situations 4 and actively teach colleagues to look out for each other and challenge in an open and non‐confrontational way, when something does not seem right.…”

“…At stressful times, the limbic system can react faster than higher brain functions resulting in, perhaps shouting at a work colleague, that we later regret. For this reason, when someone is stressed or angry we recommend pausing before speaking and allowing higher cognitive functions to catch up 4 …”