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Today we face many problems. Some are created essentially by ourselves based on divisions due to ideology, religion, race, economic status, or other factors. Therefore, the time has come for us to think on a deeper level, on the human level, and from that level we should appreciate and respect the sameness of others as human beings.
—Dalai Lama In the current healthcare environment, there is an increasing focus on providing high quality patient care at ever lower costs while patients rightly expect excellent outcomes. Cardiac surgery in particular is dependent on several disciplines working together
closely and having a good appreciation of the chal- lenges facing each one. High quality outcomes are
dependent upon a wide array of factors, ranging from
patient specific issues, to provider acumen and tech- nical skills, to ancillary support systems and increas- ingly to organizational factors.
Successful healthcare organizations understand
the importance of using teams efficiently to accom- plish difficult and complex tasks. Teams are assem- bled with a central, unifying objective in mind and
specific roles are assigned to each member in order to achieve this goal. This allows members to play to their individual skill set and operate within their comfort zone. Advanced technology, streamlined techniques, and improved science, much of which is outlined in the chapters of this text, have no doubt improved practitioner skills and enhanced care. Importantly, a shared mental model gives what would otherwise be a group of skilled individuals working in isolation the ability to successfully tackle increasingly complex tasks together. Teams generally provide a purpose and a broader sense of meaning to each member, creating a sense of mutual support which can bind individuals together.
Teams are especially critical for avoiding errors and for responding to unexpected events that can result in catastrophic complications if not managed
appropriately. The elite cardiac operating room rep- resents a delicate symphony of quick decision- making, refined technical skill and sound judgment
and other highly trained, capable healthcare providers. A hallmark feature of successful teams is effective and open communication. The cardiac operating
room is a high stakes environment where small break- downs in communication and teamwork can have
significant consequences on safe patient care and outcome. With that in mind, organizations that accredit healthcare providers, such as The Joint Commission in the United States, have pinpointed teamwork as being critical to thriving healthcare organizations that provide optimal patient care and minimize medical error. Error Before we understand teams, we must understand the root cause of error. It is increasingly recognized that most medical errors are avoidable. Rather than being related to a lapse of technical skill, poor medical
decision-making, inadequate knowledge or subopti- mal training, they are more commonly the result of a
breakdown in effective communication, in teamwork or during transition of care. Addressing system-based
issues, breakdowns in cognitive networks and advan- cing team-based approaches are essential to high
quality care. The famous human factors engineer, James Reason, described all systems as containing both active and latent failures. Active failures represent
errors made by individuals at the service delivery end
(the operating room team); latent failures are organ- izational deficiencies (hospital wide, governmental,
manufacturers, etc.) that are lurking in the back- ground contributing to active failures. Latent failures
can be thought of as the holes in the Swiss cheese. When errors occur, the majority of healthcare organizations focus on the active failures, the most obvious of failures, through investigations like root cause analyses or Morbidity & Mortality conferences. Questions typically asked are: “who made mistakes?”
or “who didn’t follow the rules?.” This type of think- ing with an emphasis on the negative has been coined
“Safety 1.” Safety 1 seeks to find the errors, the flaws,
the vulnerabilities. An alternative perspective, how- ever, has emerged called “Safety 2.” In delivering
complex, complicated healthcare we do a lot of good and most times, we do it correctly. We manage to do this despite operating in increasingly complex systems, with ever changing providers and more and more demanding patients. The reason things go right is not that people behave as they are supposed to but because people adapt to the conditions they work in to make outcomes better. Understanding how people and the systems they work in adjust in order to provide great care is how “Safety 2” is framed. Safety
2 embraces the variability in the healthcare delivery system and seeks to understand it. For example: Sally, a perfusionist, is sought-after for complicated cases. She is talented clinically, communicates well, shares what she is thinking, makes good decisions and is steady under pressure. Sally’s resilience serves the team well and, when Sally is there, it performs better.
Rather than punishing people for making poor deci- sions (Safety 1), Safety 2 seeks to understand what
Sally does well and how this can be transferred to other situations.
The two different perspectives are best summar- ized in Table 1.1.