Macroergonomics in the operating room (OR)

Macroergonomics has been applied to improving the healthcare system, one being the surgical team. Using a sociotechnical approach to improve the surgery team and overall safety is no surprise as 40% to 50% of the hospital errors occurred in the operating room (OR) (Cuschieri, 2006). Systems Engineering Initiative for Patient Safety (SEIPS) can consider the entire surgical team as a sociotechnical system that plays a role in the entire healthcare system rather than an individual, isolated team. 

System components

The surgical team classifies as a complex socio-technical system because it involves not only the surgical team itself, often including the anesthesiologist, surgeons, nurses, staff, and other specialists, and their interaction with the surgical instruments, but also government regulations, such as Health Insurance Portability and Accountability Act (HIPAA) protecting patient privacy or OR work environment. The institute's budget also determines a surgical team's system evolution and behavior, depending on which new machines they can purchase, other hospital departments such as how occupied the in-patient units are, the surgical coordinating team, the family, and ultimately the patient, which can result in system uncertainty. There is also a possibility of unpredictable emergency surgery, making the surgical team a complex, dynamic socio-technical system.

Challenges and potential for human error

As the system involves both humans and organizations, the errors can be divided into two greater categories. The first is proximal errors, which are imposed by the organization and the processes used by the team. This includes poor leadership, inadequate teamwork and training, overwork, goal conflicts, and an inadequate system for detecting poor performance (Cuschieri, 2006). One proximal error on the organization level, more like a challenge in the surgical system, is goal conflicts between the organization and the surgical team. The organization is usually geared to maximize efficiency and productivity and requesting a higher turnover rate without providing adequate resources (Cuschieri, 2006). Cuschieri further notes issues such as economic reasons posted by the organization, limiting the number of interventions that can be carried out, or the number of machines that directly affect patient safety, well-being, and potential, which is the primary goal of the surgical team. If physicians follow organization goals and eliminate the necessary treatments needed, then patients' safety is sacrificed. In addition, Holden et al. (2012) also add that not including front-line care providers, such as surgeons and nurses, input to equipment purchasing decisions will also sacrifice patient safety. Physicians have immediate contact with the patients and the required knowledge to understand which equipment is better for their specialties. However, physicians do not always receive the equipment they requested, which can also compromise patient safety.

Another potential for chaos is during emergency surgeries. This challenges the robustness of protocols and procedures outlined by the organization. Ideally, the team exhibits precise levels of communication contributed by strong leadership, which can be distinguished by the ability to direct and function in context, integrity, and professional standing (Cuschieri, 2006). Additionally, because the time for critical thinking, whether for information retrieval or decision making, in emergencies is short, physicians need to comprehend the organization's protocols and shared goals for the situation to resolve smoothly (Watters & Truskett, 2013).

The second type of error is distal errors enacted by the actual surgical team throughout the operative process (Cuschieri, 2006). The distal errors described by Cuschieri can be further divided into a few types of human errors: input error, represented by incorrect or outdated knowledge; intention error represented by lack of situational awareness; executive (psychomotor) error presented by the most known errors of commission, omission, and inition (Cuschieri, 2006; Watters & Truskett, 2013). Human errors in a surgical setting are primarily attributed to a lack of situational awareness related directly to psychomotor errors. However, errors can be minimized by maintaining good situational awareness that matches the perception of reality during planning and treatment (Watters & Truskett, 2013). Watters and Truskett explain a good situational awareness should include recognizing a patient's needs, knowing the team's capacity and resources, considering the treatment plan, and adapting to the situation to predict the likelihood of the outcomes. Having situational awareness prevents issues such as operating on the wrong side or administering the wrong dose of medication as intention error and psychomotor errors can all be prevented and allow the team to adapt to emergencies, a common occurrence in the OR.

Current Research

The measures to improve and reduce human errors in the surgical sector of healthcare have been focused on establishing a system, tackling the proximal errors mentioned. For the surgical team, the robustness of the organization protocols plays a significant role in eliminating distal errors. For example, when the organizations and the surgical team have aligned goals and provide enough resources for the front-line providers, the surgical team will not have elevated stress, disruptions, or a lack of situational awareness, decreasing the chances of psychomotor errors. Landers (2015) proposes that the main focus to correcting proximal errors is to use the three-hinge approach, which emphasizes team cohesiveness and continuous quality monitoring. One of the essential tools is a checklist. When integrating critical players in the system with checklists, the surgical teams utilize time-out strategies and checklists to reduce OR disruptions, which are the primary cause of errors. Checklists are highly adaptive and can be adjusted based on patient needs or institution goals.

References

Cuschieri, A. (2006). Nature of human error : Implications for surgical practice.Annals of Surgery, 244(5), 642-648. https://doi.org/10.1097/01.sla.0000243601.36582.18

Holden, R. J., Montague, E., Carayon, P., Hoonakker, P., Waterson, P., Wetterneck, T., Gurses, A., & Rivera-Rodriguez, A. J. (2012). Macroergonomics in Healthcare: Principles, Progress, and Prospects. Proceedings of the Human Factors and Ergonomics Society Annual Meeting, 56(1), 1293–1297. https://doi.org/10.1177/1071181312561268

Landers, R. (2015). Reducing surgical errors: Implementing a three-hinge approach to success. AORN Journal, 101(6), 657-665. https://doi.org/10.1016/j.aorn.2015.04.013

Watters, D. A. K., & Truskett, P. G. (2013). Reducing errors in emergency surgery. ANZ Journal of Surgery, 83(6), 434-437. https://doi.org/10.1111/ans.12194