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Human Error in Airway Management From Anecdotes and War Stories to True Cognitive Science

Human Error in Airway Management From 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

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Human Error in Airway Management From Anecdotes and War Stories to True Cognitive Science

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  1. Human Errorin Airway ManagementFrom Anecdotes and War Stories to True Cognitive Science D. John DoyleMD PhD FRCPC Revision 1.1 26 Slides November 2003

  2. 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

  3. 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

  4. 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

  5. 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):410-8Department of Surgery, New York University Medical Center, New York 10016, USA.

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

  7. Human Error in Hospitals and Industrial Accidents • It seems very unlikely that simple exhortation or additional regulations will help because the problemlies principally in the multiple human-machine interfaces that constitute modern medical care. • Spencer FC.Human error in hospitals and industrial accidents: current concepts. J Am Coll Surg 2000 Oct;191(4):410-8Department of Surgery, New York University Medical Center, New York 10016, USA.

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

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

  10. Human Error in Hospitals and Industrial Accidents • Second, major accidents are rarely causedby 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. • Spencer FC.Human error in hospitals and industrial accidents: current concepts. J Am Coll Surg 2000 Oct;191(4):410-8Department of Surgery, New York University Medical Center, New York 10016, USA.

  11. Slips vs. Mistakes • Reason and Navon • Slips are errors in execution • Mistakes are errors in planning an action

  12. 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

  13. 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

  14. 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.

  15. 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

  16. 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

  17. 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

  18. 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 Human Error in Airway Management

  19. 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.

  20. Self-Reporting of Deficiencies in Airway Management andVideo 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):623-35Department of Anesthesiology, University of Maryland School of Medicine, Baltimore 21201-1192, USA.

  21. 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.

  22. 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 • 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.

  23. 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 • 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.

  24. 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):1494-503Department of Anesthesiology, University of Maryland, Baltimore 21201-1192, USA. colin@anesthlab.ab.umd.edu

  25. The End

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