The Daily Dose • Sunday, April 29

Can Human Factors and Cognitive Science Make Medicine and Anesthesiology Safer?

By Dr. Carla Todaro, from the IARS 2018 Annual Meeting*

This session focused our attention on human errors, cognitive processes, unrecognized hazards and the importance of preoperative checklist.

The first questions have to be, is anesthesia safe? What are the major causes of mortality? Why this is happening?

Dr. Anna Clebone of The University of Chicago Medicine argued that although anesthesia related-mortality is currently less than 1/100:000, intraoperative critical events can still lead to undesirable outcomes and hence, there is a need of cognitive aids that lead to quicker finding of needed information during critical events.

Also from The University of Chicago Medicine, Dr. Keith Ruskin’s talk supported Dr. Clebone’s arguement. Specifically he addressed unrecognized hazards of alarm fatigue and how alarms can jeopardize safety, make the worker uncomfortable, and cause cognitive stress. Failing to notice or ignoring an alarm is often the result of a clinician’s “alarm” or “alert fatigue”. The possible solutions to alarm fatigue include technical, organizational and educational interventions. The selection of adequate monitors and the avoidance of overmonitoring, wise selection of alarm limits, and multimodal alarms can lead to a significant reduction on noise and desensitization.

Despite improving patient safety in some perioperative settings, some checklists are not particularly helpful. NASA Ames Research Center’s Dr. Barbara K. Burian proposed a framework organized around five stages of the checklist life cycle: (1) conception, (2) determination of content and design, (3) testing and validation, (4) induction, training, and implementation, and (5) ongoing evaluation, revision, and possible retirement. Let’s not rely on a standard tick box! Checklists have to be built around the structure of medical teams and the flow of their work in those settings.

Errors matter! Dr. Key Dismukes, also from NASA, illustrated how we are exposed during clinical practice to interruptions and multitasking activities. This can result in elavated tensions and make us vulnerable to errors… and it can happen to anyone!

References:

  1. Burian BK, Clebon A, Dismukes K. More Than a Tick Box: Medical Checklist Development, Design, and Use. Anesth Analg 2018: 126;223-232
  2. Ruskin KJ, Hueske-Kraus D. Alarm fatigue: impacts on patient safety. Current Opinion in Anesthesiology. 2015: 28;685-690.

*Coverage from Panel session Can Human Factors and Cognitive Science Make Medicine and Anesthesiology Safer?

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