Hierarchical Task Analysis Can Help Reduce Error in FESS

Can a hierarchical task analysis (HTA) identify and reduce risks in functional endoscopic sinus surgery (FESS)?

BOTTOM LINE
HTA and the Systematic Human Error Reduction and Prediction Approach (SHERPA) are valuable tools to deconstruct expert performance and to highlight potential errors in FESS. The HTA and SHERPA approaches to surgical procedures are useful learning and assessment tools for novice surgeons. The information derived offers the opportunity to improve surgical training and enhance patient safety by identifying high-risk steps in the procedure and how risk can be mitigated.

Background: There is large scope for error in FESS and overall complication rates of between 1% and 3% have been described in literature. New technologies and techniques including 3D navigation technology, improved equipment, better techniques and surgical safety checklists have improved technical outcomes since early endoscopic sinus surgery. Current practice for surgical training has moved away from traditional methods of practicing and teaching on live patients. Novel methods of teaching trainees including simulation are increasingly being incorporated into surgical curricula and literature in an attempt to improve patient safety. Simulation-based learning has shown promise in reducing error rates and improving time to achieving proficiency in surgical skills, but these methods have not yet been subjected to large-scale studies. HTA has been well documented in many high-reliability organizations and has led to safer working environments. These methodologies are being adapted in surgery and anesthesia as a means of improving patient safety and performance evaluation. These analyses are dependent on subjective observations and variations in clinical practice to produce a single accepted optimum method for successful completion of a procedure. This study aims to examine the process of developing an HTA for FESS and to analyze identified errors using the SHERPA methodology.

Study design: A triangulation of methods was used to derive the steps required to complete a FESS: Researchers conducted 1) a literature review of published descriptions of FESS techniques; 2) observations of three FESS; 3) interviews with surgeons on FESS techniques. Data sets were combined to develop a task analysis of a correct approach to conducting FESS. A review by 12 surgeons and observation of 25 FESS resulted in refinement of the task analysis. With input from five consultant surgeons and one consultant anesthetist, a SHERPA was used to identify the risks and mitigating steps in FESS.

Synopsis: Ten tasks and 49 subtasks required for a correct approach to completing FESS were identified based on literature review and expert consensus. A risk score for each subtask was calculated from a suitable risk matrix. Risk reduction methods at each subtask were detailed. High-scoring subtasks were evaluated and varying strategies examined to reduce the likelihood and mitigate the impact of error. The study demonstrates the usefulness of the HTA and SHERPA approach in standardization and optimization of clinical practice in order to improve patient safety.

Citation: Corbett M, O’Connor P, Byrne D, Thornton M, Keogh I. Identifying and reducing risks in functional endoscopic sinus surgery through a hierarchical task analysis. Laryngoscope Investig Otolaryngol. 2019;4:5–12.