“Code Red: Left Side of Head”?
Friday, October 16, 2009
Team training among airline crew helped passengers survive the
plane crash into the Hudson River, New York after a bird struck the
airplane engine in 2009.1 Equally important,
surgical team training is vital to avert potential problems when a
split second of hesitation or a misunderstanding can result in
injury or even death.
In 2000, the Institute of Medicine recommended team training
programs to improve patient safety.2 Additionally
in 2007, the Joint Commission prioritized improved communication as
a patient safety goal among caregivers.3 Two major
organizations have now designated team training as an important way
to improve patient safety.
The Northwestern Memorial Hospital in Chicago, USA, initiated a
team training program led by 40 trainers.4 The
educational intervention was a 4 hour team-training class led by an
operating room physician and a non-physician. Each of the 36
training classes were conducted with approximately 30 trainees.
The main goals of the training were to achieve the
- Develop leadership expertise and mutual performance
- To create a shared mental model;
- To emphasize individual accountability;
- To learn how to create pre-operative brief and post-operative
- To develop standard communication techniques, such as which
words to repeat, and;
- To develop standard terminology to indicate severity of the
condition if it escalates.
The program was assessed by hospital metrics for surgical cases
performed in the operating room where patients were under general
anesthesia. The assessment looked at issues such as:
- Administration of drugs at the wrong side and/or site;
- Timely administration of antibiotics, and;
- Cases which started on time and turn-over time between
In addition, the program looked at teamwork attitude surveys and
intra-operative observation using a checklist which consisted of
patient identification, time-out before the commencement of a
procedure, and debrief performance.
Among the 1,150 people trained, 37% felt that pre-operative
briefs helped reduce patient risk and reduced delays in starting
cases.4 Additionally, operating room efficiency was
enhanced as the number of 'on-time' starts of procedures increased.
Of note, teamwork attitude improvement was greater among nurses
than among surgeons. The errors observed during the procedures were
improper patient positioning and lack of equipment availability. At
the end of a 6-month observation period, there was decreased
performance of pre-operative briefs.4 This shows
that pre-operative briefs might not be sustainable because people
do not receive frequent reinforcement by perceiving that a disaster
could have been averted by working together as a team. While there
are an insufficient number of "near misses" in order to determine
if team training is effective, the institution is continuing the
How Can Team Training in a Dermatology Office be
Attitude of Team Members
There is an immediate benefit in the team members' attitudes.
When you consider the time and effort that it takes to train a
surgical assistant or other members of staff, dermatologists might
choose to use any possible means to improve attitude in order to
retain personnel. Reduction in turn-over time of procedure rooms
could be a major benefit to the busy practice. Lastly, there is the
possibility that performance of team training could reduce
malpractice premiums just as office accreditation lowers liability
Team training exercises might specify the phrases to be used in
case of an emergency, such as when a fire occurs in a procedure
room. For example, say a laser ignites an alcohol sponge left near
the head of the patient. What do you say to alert staff to the
"Code red: left side of head"?
The team needs to know what "code red" means as well as knowing
that the location given is with respect to the patient's head and
not the doctor's head. After staff are alerted, the laser is
switched off, and the flames are smothered. What happens if the
flames start to spread? Who calls 911? Who stabilizes the patient,
escorts the patient from the procedure room, and makes the decision
to continue to monitor the patient? Where is the nearest exit? Does
the office staff know how to evacuate the exam rooms and the
waiting area? Who makes a sweep of the office to be sure that
everyone is out of the suite? Where do the staff and patients
assemble outside the building?
Team training with someone assuming the role of the patient
helps people review, practice, and execute the plan. A fire drill
demonstrating how to use the fire extinguisher once a year is also
important. For new members of staff, fire drill training should be
part of the orientation. Other team training exercises could be
developed around cardiac arrest, obstructed airway, and difficulty
controlling bleeding (see Table 1 below).
Table 1. Suggestions for dermatology office
|Emergency drills for hazards such as fire or floods. Record the
date and those in attendance.
|Review and modify patient post-operative care handouts.
|Physicians should monitor the laboratory log. The log notes the
day the specimen is submitted, results received and results
provided to patient and recommended action. If a report is missing,
action is taken.
|Equipment maintenance logs with inspection notes shown on hang
|Review and modify the risk management program.
The training program should include the following tasks to keep
the office functioning smoothly every day:
Common Patient Situations in the Office
Alleviating anxiety in the pre-operative patient, and escorting
and calming the complaining patient from the premises out the side
door rather than through the waiting room are two common events
that are managed with as little "drama" as possible by the team
working together to develop scenarios. Role playing by
members of the team can make the experience meaningful . Staff can
share "tips" with each other. The staff and physicians on the
receiving end of verbal abuse from angry patients might experience
anxiety and this can be relieved by sharing their experiences,
being comforted by others, and by having a good laugh.
Lastly, there are the necessary tasks that keep the office
running. Who performs equipment checks? How frequently are large
pieces of equipment maintained? Does the suction instrument have a
hang tag with maintenance inspections noted? Equipment that
is rarely used and often stored in out of the way places is easily
overlooked when performing routine maintenance. For instance the
crash cart, which is tucked away in a closet, may be forgotten.
When a patient has an acute allergic or vasovagal reaction, it is
important for the team to react swiftly with a crash cart that
contains diphenhydramine, epinephrine for subcutaneous injection,
blood pressure cuff, stethoscope, intravenous needles, lines and
fluids, glucometer. Where is the oral sugar bolus? Is the oxygen
tank easily opened? Is the tank full? Are the staff trained in the
use of these items and can the patient be placed in Trendelenberg
position rapidly with the examination table? Has the team practiced
using the crash cart? Who checks the expiration dates on the
medications, replaces them, and affixes a sticker to the cart
noting the date that the maintenance was performed?
Surgical instruments need routine maintenance by the person who
cleans the instruments. Scissors need to be checked for sharpness
by cutting a piece of paper without undue force or leaving jagged
edges. Clamps need to have their tips checked for alignment during
closing. The fluid movement of needle drivers can be preserved by
hand-brushing debris from the lock boxes during cleaning.
Most of those who read this article will think that the office
manager already does all of this. Perhaps it would be a good idea
to ask the office manager to see the emergency evacuation plan.
Have you ever participated in a team training session? If yes, then
give yourself a pat on the back. If not, why not? The physician is
an integral part of the team.
- Helmreich RL, Wilhelm JA. Outcomes of crew resource management
training. Int J Aviat
- Institute of Medicine: Kohn LT, Corrigan JM, Donaldson MS,
eds. To err is human: building a safer health
system. Washington, DC. National Academy Press;
- The Joint Commission National Patient Safety
Goals. Accessed August 2009.
- Halverson AL, Andersson JL, Anderson K, et al.
Surgical team training: The Northwestern Memorial Hospital