human error in airway management from anecdotes and war stories to true cognitive science d. john...

Human Error

in Airway ManagementFrom Anecdotes and War Stories to True Cognitive Science

D. John Doyle MD PhD FRCPC

Revision 1.1

26 Slides

November 2003

Outline

• Human error in medicine

• Airway war stories

• The science of human error

• The root causes leading to human error

• Human error in airway management (University of Maryland research studies)

• Efforts to reduce error in airway management

Objectives

• Learn a bit about the nature of human error

• Understand the limitations of punishment as a means of responding to human error

• Apply these concepts to the field of clinical airway management

To Err is Human

It has been repeatedly said, over thousands of years, that to err is part of being human. For example:

1) ERRARE HUMANUM EST; to err is human. (Probably a variation on Plutarch, Morals, c 100 AD)

2) "I presume you're mortal, and may err." (Shirley, The Lady of Pleasure, 1635)

3) "To err is human; to forgive divine." (Pope, Essay on Criticism 1711)

4) "To err is human; to forgive is against company policy." (Senders, various, 1978)

All of these state that errors will be made by people despite their determination to avoid them. Yet people are consistently held accountable for their errors when they lead to accidents with adverse outcomes. Is this proper? I argue that it is not, in the same way that in law no-one is held accountable for acts of God.

John W. Senders, Ph. D. http://www.ergogero.com/hosp/hosphome.html

http://www.ergogero.com/hosp/hosphome.html

Human Error in Hospitals and Industrial Accidents

Most data concerning errors and accidents are from

industrial accidents and airline injuries.

General Electric, Alcoa, and Motorola, among

others, all have reported complex programs that

resulted in a marked reduction in frequency of

worker injuries.

Spencer FC. Human error in hospitals and industrial accidents: current concepts. J Am Coll Surg 2000 Oct;191(4):410-8 Department of Surgery, New York University Medical Center, New York 10016, USA.


In the field of medicine, however, with the

outstanding exception of anesthesiology, there is a

paucity of information, most reports referring to

the 1984 Harvard-New York State Study, more than

16 years ago. This scarcity of information indicates

the complexity of the problem.



It seems very unlikely that simple exhortation

or additional regulations will help because the

problem lies principally in the multiple human-

machine interfaces that constitute modern

medical care.



Concurrent with the studies of industrial and

nuclear accidents, cognitive psychologists have

intensively studied how the brain stores and

retrieves information. Several concepts have

emerged.



First, errors are not character defects to be treated

by the classic approach of discipline and education,

but are byproducts of normal thinking that occur

frequently.



Second, major accidents are rarely caused by a

single error; instead, they are often a combination

of chronic system errors, termed latent errors.

Identifying and correcting these latent errors

should be the principal focus for corrective

planning rather than searching for an individual

culprit.


Slips vs. Mistakes

Reason and Navon

•Slips are errors in execution

•Mistakes are errors in planning an action

Slips vs. Mistakes

When is an action a slip or a mistake?

Scenario: Pressing the red rather than the blue button, leads to an unwanted consequence.

If the (correct) intention was to press the blue button, then the action was a slip.

If the intention was to press the red button, then the action was a mistake.

http://hydro.energy.kyoto-u.ac.jp/Lab/CSE/CSE6/tsld019.htm

Human Error in Medicine

Diagnostic Process: Failure to employ indicated tests; Misreading lab results; Failure to act on the results of monitoring or testing.

Treatment: Technical error in performance; Error in preparation the treatment (e.g. dosage); Delayed treatment or inappropriate care.

Preventive (failure to provide prophylactic treatment): Inadequate monitoring, Inadequate follow-up of treatment.

Other: Failure to communicate; Equipment failure; Situated environments (OR and ICU)http://camis.stanford.edu/people/felciano/research/humanerror/humanerrortalk.html

Human Error in Airway Management: Examples

Diagnostic Process: Failure to recognize esophageal intubation

Treatment: Delayed reintubation in the PACU.

Preventive (failure to provide prophylactic treatment): Inadequate monitoring of respiration, Inadequate follow-up of patient after extubation.

Other: Failure to communicate about a difficult airway by not writing a note in the chart.

Swain and Guttman’s (1980)Human Error Categories

Error of Omission

Typographicl errrs

Error of Commission

Hitting thumb with hammer

Extraneous Act

Reading wrong report

Sequential Error

Lighting a fire before opening the damper

Time Error

Running a red light

http://camis.stanford.edu/people/felciano/research/humanerror/humanerrortalk.html

Swain and Guttman’s (1980) Human Error Categories: Airway Examples

Error of Omission

Forgetting to inflate the ETT cuff

Error of Commission

Breaking a tooth while intubating

Extraneous Act

Drawing up drugs not needed

Sequential Error

Giving drugs before checking equipment

Time Error

Intubating too early when relaxation is suboptimal

Some Airway Errors• Incorrect technique (eg, LMA where ETT is

needed)• Esophageal intubation• Intubation incorrect route (eg, oral instead of

nasal)• Intubation incorrect tube (eg, RAE instead of

armored ETT)• Endobronchial intubation• Wrong cuff pressure• Incorrect precautions against aspiration

Human Error in Airway Management

• Poor planning• Poor arrangement of

workspace• No testing of equipment

before procedure• Lack of knowledge• No knowledge of ASA

algorithm

• Poor judgment• Limited experience• Hubris• Denial• Failure to arrange for help

before trouble starts• Failure to call for help

when trouble starts

Video analysis of two emergency tracheal intubations identifies flawed decision-making.

Mackenzie CF, Craig GR, Parr MJ, Horst R. Video analysis of two emergency tracheal intubations identifies flawed decision-making. The Level One Trauma Anesthesia Simulation Group. Anesthesiology 1994 Sep;81(3):763-71

Department of Anesthesiology, University of Maryland, Baltimore.

Self-Reporting of Deficiencies in Airway Management and Video Analyses of Actual Performance.

Compared the performance deficiencies of airway management captured by three types of self-reports with those identified through video analysis.

Mackenzie CF, Jefferies NJ, Hunter WA, Bernhard WN, Xiao Y. Comparison of self-reporting of deficiencies in airway management with video analyses of actual performance. LOTAS Group. Level One Trauma Anesthesia Simulation. Hum Factors 1996 Dec;38(4):623-35 Department of Anesthesiology, University of Maryland School of Medicine, Baltimore 21201-1192, USA.

Mackenzie CF, Jefferies NJ, Hunter WA, Bernhard WN, Xiao Y. Comparison of self-reporting of deficiencies in airway management with video analyses of actual performance. LOTAS Group. Level One Trauma Anesthesia Simulation. Hum Factors 1996 Dec;38(4):623-35

The three types of self-reports were:

- the anesthesia record (a patient record constructed during the course of treatment),

- the anesthesia quality assurance (AQA) report (a retrospective report as a part of the trauma center's quality assurance process),

- and a posttrauma treatment questionnaire (PTQ), which was completed immediately after the case for the purposes of this research.


Video analysis of 48 patient encounters identified 28 performance deficiencies related to airway management in 11 cases (23%). The performance deficiencies took the form of task omissions or practices that lessened the margin of patient safety.

In comparison, AQA reports identified none of these performance deficiencies, the anesthesia records identified 2 (of 28), and the PTQs suggested contributory factors and corrective measures for 5 deficiencies.


Video analysis provided information about the context of and factors contributing to the identified performance deficiencies, such as failures in adherence to standard operating procedures and in communications.

Retrospective video analysis of prolonged uncorrected esophageal intubation.

Mackenzie CF, Martin P, Xiao Y. Video analysis of prolonged uncorrected esophageal intubation. Level One Trauma Anesthesia Simulation Group. Anesthesiology 1996 Jun;84(6):1494-503

Department of Anesthesiology, University of Maryland, Baltimore 21201-1192, USA. [email protected]

The End

human error in airway management from anecdotes and war stories to true cognitive science d. john...

Documents

human error human error

science of human error

nature of human error

nuclear accidents

studies of industrial

current concepts

harvardnew york state

department of surgery