153 results for Merry, Alan, Journal article

  • The challenges of technological intensification

    Webster, Craig; Stabile, M; Merry, Alan (2009)

    Journal article
    The University of Auckland Library

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  • Teamwork, communication, formula-one racing and the outcomes of cardiac surgery

    Merry, Alan; Weller, Jennifer; Mitchell, Simon (2014-03)

    Journal article
    The University of Auckland Library

    Most cardiac units achieve excellent results today, but the risk of cardiac surgery is still relatively high, and avoidable harm is common. The story of the Green Lane Cardiothoracic Unit provides an exemplar of excellence, but also illustrates the challenges associated with changes over time and with increases in the size of a unit and the complexity of practice today. The ultimate aim of cardiac surgery should be the best outcomes for (often very sick) patients rather than an undue focus on the prevention of error or adverse events. Measurement is fundamental to improving quality in health care, and the framework of structure, process, and outcome is helpful in considering how best to achieve this. A combination of outcomes (including some indicators of important morbidity) with key measures of process is advocated. There is substantial evidence that failures in teamwork and communication contribute to inefficiency and avoidable harm in cardiac surgery. Minor events are as important as major ones. Six approaches to improving teamwork (and hence outcomes) in cardiac surgery are suggested. These are: 1) subspecialize and replace tribes with teams; 2) sort out the leadership while flattening the gradients of authority; 3) introduce explicit training in effective communication; 4) use checklists, briefings, and debriefings and engage in the process; 5) promote a culture of respect alongside a commitment to excellence and a focus on patients; 6) focus on the performance of the team, not on individuals.

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  • Improved scores for observed teamwork in the clinical environment following a multidisciplinary operating room simulation intervention

    Weller, Jennifer; Cumin, David; Civil, Ian; Torrie, Jocelyn; Garden, A; MacCormick, Andrew; Gurusinghe, N; Boyd, M; Frampton, C; Selander, L; Cokorilo, M; Tranvik, M; Carlsson, L; Lee, T; Ng, WL; Crossan, Michael; Merry, Alan (2016)

    Journal article
    The University of Auckland Library

    AIMS: We ran a Multidisciplinary Operating Room Simulation (MORSim) course for 20 complete general surgical teams from two large metropolitan hospitals. Our goal was to improve teamwork and communication in the operating room (OR). We hypothesised that scores for teamwork and communication in the OR would improve back in the workplace following MORSim. We used an extended Behavioural Marker Risk Index (BMRI) to measure teamwork and communication, because a relationship has previously been documented between BMRI scores and surgical patient outcomes. METHODS: Trained observers scored general surgical teams in the OR at the two study hospitals before and after MORSim, using the BMRI. RESULTS: Analysis of BMRI scores for the 224 general surgical cases before and 213 cases after MORSim showed BMRI scores improved by more than 20% (0.41 v 0.32, p<0.001). Previous research suggests that this improved teamwork score would translate into a clinically important reduction in complications and mortality in surgical patients. CONCLUSIONS: We demonstrated an improvement in scores for teamwork and communication in general surgical ORs following our intervention. These results support the use of simulation-based multidisciplinary team training for OR staff to promote better teamwork and communication, and potentially improve outcomes for general surgical patients.

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  • Response to: Improving the Quality and Safety as Well as Reducing the Cost for Patients Undergoing Cardiac Surgery: Missing Some Issues?

    Merry, Alan; Weller, Jennifer; Mitchell, Simon (2015-08)

    Journal article
    The University of Auckland Library

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  • Role of anesthesiologists in WHO safe surgery programs

    Merry, Alan (2010)

    Journal article
    The University of Auckland Library

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  • In Reply

    Gargiulo, Derryn; Mitchell, Simon; Sheridan, Jane; Short, TG; Swift, Simon; Torrie, Jocelyn; Webster, Craig; Merry, Alan (2016-10)

    Journal article
    The University of Auckland Library

    We thank Tafelski et al. for making some interesting points about our recent study1 and asking for clarification of some issues. We agree that for various reasons, our results may be an underestimate, and we discussed these in some length in our article. With respect to the Hawthorne effect, we agree that our findings may reflect an underestimation of the actual rate of syringe contamination. Indeed, in the article, we indicated that “anesthesiologists were encouraged to behave ‘normally’ in respect of their aseptic practice,” but that “the open-label nature of the study may have influenced them to be more fastidious.”

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  • Multidisciplinary operating room simulation-based team training to reduce treatment errors: a feasibility study in New Zealand hospitals

    Weller, Jennifer; Cumin, David; Torrie, Jocelyn; Boyd, M; Civil, Ian; Madell, D; MacCormick, Andrew; Gurisinghe, N; Garden, A; Crossan, Michael; Ng, WL; Johnson, S; Corter, Arden; Lee, T; Selander, L; Cokorilo, M; Merry, Alan (2015-07-24)

    Journal article
    The University of Auckland Library

    Communication failures in healthcare are frequent and linked to adverse events and treatment errors. Simulation-based team training has been proposed to address this. We aimed to explore the feasibility of a simulation-based course for all members of the operating room (OR) team, and to evaluate its effectiveness.Members of experienced OR teams were invited to participate in three simulated clinical events using an integrated surgical and anesthesia model. We collected information on costs, Behavioural Marker of Risk Index (BMRI) (a measure of team information sharing) and participants' educational gains.We successfully recruited 20 full OR teams. Set up costs were NZ$50,000. Running costs per course were NZ$4,000, excluding staff. Most participants rated the course highly. BMRI improved significantly (P = 0.04) and thematic analysis identified educational gains for participants.We demonstrated feasibility of multidisciplinary simulation-based training for surgeons, anesthetists, nurses and anaesthetic technicians. The course showed evidence of participant learning and we obtained useful information on cost. There is considerable potential to extend this type of team-based simulation to improve the performance of OR teams and increase safety for surgical patients.

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  • Assessing the similarity of mental models of operating room team members and implications for patient safety: a prospective, replicated study

    Nakarada-Kordic, Ivana; Weller, Jennifer; Webster, Craig; Cumin, David; Frampton, C; Boyd, M; Merry, Alan (2016)

    Journal article
    The University of Auckland Library

    BACKGROUND: Patient safety depends on effective teamwork. The similarity of team members' mental models - or their shared understanding-regarding clinical tasks is likely to influence the effectiveness of teamwork. Mental models have not been measured in the complex, high-acuity environment of the operating room (OR), where professionals of different backgrounds must work together to achieve the best surgical outcome for each patient. Therefore, we aimed to explore the similarity of mental models of task sequence and of responsibility for task within multidisciplinary OR teams. METHODS: We developed a computer-based card sorting tool (Momento) to capture the information on mental models in 20 six-person surgical teams, each comprised of three subteams (anaesthesia, surgery, and nursing) for two simulated laparotomies. Team members sorted 20 cards depicting key tasks according to when in the procedure each task should be performed, and which subteam was primarily responsible for each task. Within each OR team and subteam, we conducted pairwise comparisons of scores to arrive at mean similarity scores for each task. RESULTS: Mean similarity score for task sequence was 87 % (range 57-97 %). Mean score for responsibility for task was 70 % (range = 38-100 %), but for half of the tasks was only 51 % (range = 38-69 %). Participants believed their own subteam was primarily responsible for approximately half the tasks in each procedure. CONCLUSIONS: We found differences in the mental models of some OR team members about responsibility for and order of certain tasks in an emergency laparotomy. Momento is a tool that could help elucidate and better align the mental models of OR team members about surgical procedures and thereby improve teamwork and outcomes for patients.

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  • Improved compliance with the World Health Organization Surgical Safety Checklist is associated with reduced surgical specimen labelling errors

    Martis, WR; Sturge, Jacqueline; Lee, T; Merry, Alan; Mitchell, Simon (2016-09-09)

    Journal article
    The University of Auckland Library

    AIMS: A new approach to administering the surgical safety checklist (SSC) at our institution using wall-mounted charts for each SSC domain coupled with migrated leadership among operating room (OR) sub-teams, led to improved compliance with the Sign Out domain. Since surgical specimens are reviewed at Sign Out, we aimed to quantify any related change in surgical specimen labelling errors. METHODS: Prospectively maintained error logs for surgical specimens sent to pathology were examined for the six months before and after introduction of the new SSC administration paradigm. We recorded errors made in the labelling or completion of the specimen pot and on the specimen laboratory request form. Total error rates were calculated from the number of errors divided by total number of specimens. Rates from the two periods were compared using a chi square test. RESULTS: There were 19 errors in 4,760 specimens (rate 3.99/1,000) and eight errors in 5,065 specimens (rate 1.58/1,000) before and after the change in SSC administration paradigm (P=0.0225). CONCLUSIONS: Improved compliance with administering the Sign Out domain of the SSC can reduce surgical specimen errors. This finding provides further evidence that OR teams should optimise compliance with the SSC.

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  • Paperless anesthesia: uses and abuses of these data

    Anderson, Brian; Merry, Alan (2015-12)

    Journal article
    The University of Auckland Library

    Demonstrably accurate records facilitate clinical decision making, improve patient safety, provide better defense against frivolous lawsuits, and enable better medical policy decisions. Anesthesia Information Management Systems (AIMS) have the potential to improve on the accuracy and reliability of handwritten records. Interfaces with electronic recording systems within the hospital or wider community allow correlation of anesthesia relevant data with biochemistry laboratory results, billing sections, radiological units, pharmacy, earlier patient records, and other systems. Electronic storage of large and accurate datasets has lent itself to quality assurance, enhancement of patient safety, research, cost containment, scheduling, anesthesia training initiatives, and has even stimulated organizational change. The time for record making may be increased by AIMS, but in some cases has been reduced. The question of impact on vigilance is not entirely settled, but substantial negative effects seem to be unlikely. The usefulness of these large databases depends on the accuracy of data and they may be incorrect or incomplete. Consequent biases are threats to the validity of research results. Data mining of biomedical databases makes it easier for individuals with political, social, or economic agendas to generate misleading research findings for the purpose of manipulating public opinion and swaying policymakers. There remains a fear that accessibility of data may have undesirable regulatory or legal consequences. Increasing regulation of treatment options during the perioperative period through regulated policies could reduce autonomy for clinicians. These fears are as yet unsubstantiated.

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  • Can team training make surgery safer? Lessons for national implementation of a simulation-based programme

    Weller, Jennifer; Civil, Ian; Torrie, Jocelyn; Cumin, David; Garden, A; Corter, A; Merry, Alan (2016-10-14)

    Journal article
    The University of Auckland Library

    AIM: Unintended patient harm is a major contributor to poor outcomes for surgical patients and often reflects failures in teamwork. To address this we developed a Multidisciplinary Operating Room Simulation (MORSim) intervention to improve teamwork in the operating room (OR) and piloted it with 20 OR teams in two of the 20 District Health Boards in New Zealand prior to national implementation. In this study, we describe the experience of those exposed to the intervention, challenges to implementing changes in clinical practice and suggestions for successful implementation of the programme at a regional or national level. METHODS: We undertook semi-structured interviews of a stratified random sample of MORSim participants 3-6 months after they attended the course. We explored their experiences of changes in clinical practice following MORSim. Interviews were recorded, transcribed and analysed using a general inductive approach to develop themes into which interview data were coded. Interviews continued to the point of thematic saturation. RESULTS: Interviewees described adopting into practice many of the elements of the MORSim intervention and reported positive experiences of change in communication, culture and collaboration. They described sharing MORSim concepts with colleagues and using them in teaching and orientation of new staff. Reported barriers to uptake included uninterested colleagues, limited team orientation, communication hierarchies, insufficient numbers of staff exposed to MORSim and failure to prioritise time for team information sharing such as pre-case briefings. CONCLUSION: MORSim appears to have had lasting effects on reported attitudes and behaviours in clinical practice consistent with more effective teamwork and communication. This study adds to the accumulating body of evidence on the value of simulation-based team training and offers suggestions for implementing widespread, regular team training for OR teams.

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  • Bow-tie diagrams for risk management in anaesthesia

    Culwick, MD; Merry, Alan; Clarke, DM; Taraporewalla, KJ; Gibbs, NM (2016-11)

    Journal article
    The University of Auckland Library

    Bow-tie analysis is a risk analysis and management tool that has been readily adopted into routine practice in many high reliability industries such as engineering, aviation and emergency services. However, it has received little exposure so far in healthcare. Nevertheless, its simplicity, versatility, and pictorial display may have benefits for the analysis of a range of healthcare risks, including complex and multiple risks and their interactions. Bow-tie diagrams are a combination of a fault tree and an event tree, which when combined take the shape of a bow tie. Central to bow-tie methodology is the concept of an undesired or 'Top Event', which occurs if a hazard progresses past all prevention controls. Top Events may also occasionally occur idiosyncratically. Irrespective of the cause of a Top Event, mitigation and recovery controls may influence the outcome. Hence the relationship of hazard to outcome can be viewed in one diagram along with possible causal sequences or accident trajectories. Potential uses for bow-tie diagrams in anaesthesia risk management include improved understanding of anaesthesia hazards and risks, pre-emptive identification of absent or inadequate hazard controls, investigation of clinical incidents, teaching anaesthesia risk management, and demonstrating risk management strategies to third parties when required.

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  • Perspective on Cerebral Microemboli in Cardiac Surgery: Significant Problem or Much Ado About Nothing?

    Mitchell, Simon; Merry, Alan (2015-03)

    Journal article
    The University of Auckland Library

    From the time an association was perceived between cardiac surgery and post-operative cognitive dysfunction (POCD), there has been interest in arterial microemboli as one explanation. A succession of studies in the mid-1990s reported a correlation between microemboli exposure and POCD and there followed a focus on microemboli reduction (along with other strategies) in pursuit of peri-operative neuroprotection. There is some evidence that the initiatives developed during this period were successful in reducing neurologic morbidity in cardiac surgery. More recently, however, there is increasing awareness of similar rates of POCD following on and off pump cardiac operations, and following many other types of surgery in elderly patients. This has led some to suggest that cardiopulmonary bypass (CPB) and microemboli exposure by implication are non-contributory. Although the risk factors for POCD may be more patient-centered and multifactorial than previously appreciated, it would be unwise to assume that CPB and exposure to microemboli are unimportant. Improvements in CPB safety (including emboli reduction) achieved over the last 20 years may be partly responsible for difficulty demonstrating higher rates of POCD after cardiac surgery involving CPB in contemporary comparisons with other operations. Moreover, microemboli (including bubbles) have been proven harmful in experimental and clinical situations uncontaminated by other confounding factors. It remains important to continue to minimize patient exposure to microemboli as far as is practicable.

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  • Focus on thrombin: alternative anticoagulants.

    Merry, Alan (2007-12)

    Journal article
    The University of Auckland Library

    Unfractionated heparin and protamine have been integral to cardiopulmonary bypass since cardiac surgery was first undertaken. These drugs are inexpensive and well understood but are contraindicated in some individuals, and resistance to heparin can be problematic in others. The interplay between the endothelium, anticoagulants, the coagulation cascade, and the inflammatory response that characterizes cardiac surgery may contribute to some of the complications associated with cardiopulmonary bypass. Various alternative drugs and strategies have been used to manage patients unsuitable for heparin or protamine, but each has its own disadvantages. At present, direct thrombin inhibitors may offer the best available alternative to heparin in cardiac surgery, particularly the short-acting bivalirudin, but this class of anticoagulants is relatively expensive and has no reversal agent. Balanced anticoagulation using combinations of drugs that act at different stages in the coagulation system may improve the management of coagulation in cardiac surgery, but careful investigation of this concept is needed.

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  • Medication errors: time for a national audit?

    Merry, Alan; Anderson, Brian (2011-11)

    Journal article
    The University of Auckland Library

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  • Ethics, Industry and Outcomes

    Merry, Alan (2008-03)

    Journal article
    The University of Auckland Library

    Evidence-based medicine depends on research that is reliable, well conducted, and free of influence from interest groups (which are not confined to industry). There are many ways to influence the outcome of clinical research, and the history of influence in research related to tobacco is illuminating in this regard. Health care depends on industry, and if properly managed, the relationship between industry and medical academia can be symbiotic. Achieving positive outcomes from such relationships depends on ensuring the presence of the elements needed for reasonable independence on the part of investigators, and on understanding the ways in which influence can be exerted over the production and publication of evidence. Regulation cannot substitute for integrity, particularly the integrity of the investigators. Pushing the limits of ethics in research threatens to undermine not only the reputation of those conducting the research but also the standing of science itself.

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  • Use of a new task-relevant test to assess the effects of shift work and drug labelling formats on anesthesia trainees' drug recognition and confirmation.

    Cheeseman, James; Webster, Craig; Pawley, Matthew; Francis, Margaret; Warman, Guy; Merry, Alan (2011-01)

    Journal article
    The University of Auckland Library

    Background Drug administration errors occur in every aspect of clinical practice. Using a novel task-relevant Medication Recognition and Confirmation Test (MRCT), we investigated the effects on performance of working night and day shifts and labelling different drug formats. Methods Anesthesia trainees (n = 18) participated in one of two experiments during an 8-12 hr day shift and an 8-12 hr night shift. In Experiment-1 (n = 10), we compared standardized colour-coded labels with pictures of ampoules. In Experiment-2 (n = 8), we compared colourcoded labels with black and white labels. Sleep was measured with wrist actigraphy during both day and night shift runs over seven to eight days. The MRCT outcome measures were reaction times and drug errors. Results In the two experiments, colour-coded labels were recognized (and therefore selected) more quickly than pictures of conventional ampoules (mean difference 332 msec, 95% confidence interval (CI) 242-422 msec; P\0.0001) and faster than black and white labels (mean difference 96 msec, 95% CI 46-146 msec; P\0.0001). Participants obtained less sleep while working night shifts than while working day shifts (mean difference 57 min, 95% CI 0:15-1:39 hr; P = 0.013). Mean confirmation reaction times were slower during night shifts than during day shifts (mean difference 60 msec, 95% CI 1-120 msec; P = 0.048). No differences in error rates were observed between shifts or among drug label types. Conclusions Label format influenced recognition and confirmation reaction times to representations of drugs in this study, and we found some evidence to suggest that performance is better during day shifts than during night shifts. The task-relevant test evaluated here may have further application in measuring performance in the wider clinical setting.aspect of clinical practice. Using a novel task-relevant Medication Recognition and Confirmation Test (MRCT), we investigated the effects on performance of working night and day shifts and labelling different drug formats. Methods Anesthesia trainees (n = 18) participated in one of two experiments during an 8-12 hr day shift and an 8-12 hr night shift. In Experiment-1 (n = 10), we compared standardized colour-coded labels with pictures of ampoules. In Experiment-2 (n = 8), we compared colourcoded labels with black and white labels. Sleep was measured with wrist actigraphy during both day and night shift runs over seven to eight days. The MRCT outcome measures were reaction times and drug errors. Results In the two experiments, colour-coded labels were recognized (and therefore selected) more quickly than pictures of conventional ampoules (mean difference 332 msec, 95% confidence interval (CI) 242-422 msec; P\0.0001) and faster than black and white labels (mean difference 96 msec, 95% CI 46-146 msec; P\0.0001). Participants obtained less sleep while working night shifts than while working day shifts (mean difference 57 min, 95% CI 0:15-1:39 hr; P = 0.013). Mean confirmation reaction times were slower during night shifts than during day shifts (mean difference 60 msec, 95% CI 1-120 msec; P = 0.048). No differences in error rates were observed between shifts or among drug label types. Conclusions Label format influenced recognition and confirmation reaction times to representations of drugs in this study, and we found some evidence to suggest that performance is better during day shifts than during night shifts. The task-relevant test evaluated here may have further application in measuring performance in the wider clinical setting.

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  • Postoperative ischemia and cognitive impairment in cardiac surgery patients.

    Barber, Peter; Tippett, Lynette; Merry, Alan; Hach, Sylvia; Frampton, CM; Milsom, P (2009)

    Journal article
    The University of Auckland Library

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  • Cerebral ischemic lesions on diffusion-weighted imaging are associated with neurocognitive decline after cardiac surgery

    Barber, Peter; Hach, Sylvia; Tippett, Lynette; Ross, L; Merry, Alan; Milsom, Paget (2008-05)

    Journal article
    The University of Auckland Library

    Background and Purpose—Improvements in cardiac surgery mortality and morbidity have focused interest on the neurological injury such as stroke and cognitive decline that may accompany an otherwise successful operation. We aimed to investigate (1) the rate of stroke, new ischemic change on MRI, and cognitive impairment after cardiac valve surgery; and (2) the controversial relationship between perioperative cerebral ischemia and cognitive decline. Methods—Forty patients (26 men; mean [SD] age 62.1 [13.7] years) undergoing intracardiac surgery (7 also with coronary artery bypass grafting) were studied. Neurological, neuropsychological, and MRI examinations were performed 24 hours before surgery and 5 days (MRI and neurology) and 6 weeks (neuropsychology and neurology) after surgery. Cognitive decline from baseline was determined using the Reliable Change Index. Results—Two of 40 (5%) patients had perioperative strokes and 22 of 35 (63%) tested had cognitive decline in at least one measure (range, 1 to 4). Sixteen of 37 participants (43%) with postoperative imaging had new ischemic lesions (range, 1 to 17 lesions) with appearances consistent with cerebral embolization. Cognitive decline was seen in all patients with, and 35% of those without, postoperative ischemic lesions (P 0.001), and there was an association between the number of abnormal cognitive tests and ischemic burden (P 0.001). Conclusion—We have provided a reliable estimate of the rate of stroke, postoperative ischemia, and cognitive impairment at 6 weeks after cardiac valve surgery. Cognitive impairment is associated with perioperative ischemia and is more severe with greater ischemic load. (Stroke. 2008;39:1427-1433.)

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  • The effect of time of day on the duration of neuromuscular blockade elicited by rocuronium

    Cheeseman, James; Merry, Alan; Pawley, Matthew; De Souza, RL; Warman, Guy (2007)

    Journal article
    The University of Auckland Library

    In a prospective, observational trial, we investigated the influence of time of day on the duration of neuromuscular blockade (NMB) elicited by rocuronium. Forty-nine patients scheduled for surgery between 08:00 and 02:00 were enrolled after giving written informed consent. Time to neuromuscular recovery was measured following three doses: (1) a fat-free-mass (FFM) related induction dose (0.6 mg.kg)1: n = 47); (2) a maintenance dose (20% of the induction dose: n = 42); and (3) a standard 10-mg dose (n = 35). The extent of NMB was dependent on the time of administration (p = 0.038 General Linear Model Analysis). The maximum effect of 50 min (95% CI 41–59 min) was elicited between 08:00 and 11:00 and the minimum duration of 29 min (95% CI 23–35 min) between 14:00 and 17:00 (p = 0.005). A similar pattern was observed for the maintenance dose. The duration of action of rocuronium is influenced by time of day and this effect is of potential clinical significance and practical relevance to research.

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