Spotlight Case September 2003

1. Spotlight Case September 2003 Infant Paralyzed for Intubation Before Airway Materials Ready

2. Source and Credits • This presentation is based on the Sept. 2003 AHRQ WebM&M Spotlight Case in Pediatrics • See the full article at http://webmm.ahrq.gov • CME credit is available through the Web site • Commentary by: Matthew B. Weinger, MD, University of California, San Diego; George T. Blike, MD, Dartmouth College of Medicine • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Tracy Minichiello, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Understand and apply a structured method of human factors case analysis • Describe the key components of effective teamwork • Understand the importance of and the barriers to effective interpersonal communication • Design effective interventions to address deficiencies in teamwork and communication

4. Case: Infant Paralyzed A 17-month-old baby girl in the PICU developed acute respiratory failure. While setting up the laryngoscope and endotracheal tube, the PICU physician gave a verbal order for atropine, etomidate, and rocuronium. Shortly thereafter, but prior to intubation, the infant acutely desaturated. She was immediately intubated and her respiratory status was stabilized.

5. Case (cont.): Infant Paralyzed Upon review of the event, the team discovered that the nurse was new to the PICU. She had not realized the medication was a paralytic agent, and thus administered it before the intubation tray was ready, resulting in the infant’s desaturation. The physician who ordered the medication had not indicated the timing of administration nor that the medication was to be drawn up but not given until later.

6. Five Stages in Reviewing an Error: Human Factors Approach • Contact event reporter to gather complete facts of the event (what/when/how, etc.) • Interviews of participants are often necessary • Review incident for management problems • Did care deviate beyond safe limits? • If so, did deviation have potential to cause patient harm?

7. Five Stages in Reviewing an Error: Human Factors Approach 3. Perform “contributory factor analysis” using a checklist of items 4. Prioritize contributory factors that pose significant threat based on the risk analysis matrix 5. Design and implement countermeasures to actively “manage” this and similar errors

8. Contributory Factor Analysis • Patient Factors • Patient condition • Clinician–patient communication • Availability/accuracy of test results • Task Factors • Task design and clarity of structure • Availability and use of protocols

9. Contributory Factor Analysis (cont.) • Practitioner Factors • Knowledge, skills, rules • Attention • Strategy • Motivation & attitude • Physical or mental health

10. Contributory Factor Analysis (cont.) • Team Factors • Verbal or written communication • Supervision, seeking help • Team structure and leadership • Working Conditions • Staffing levels, skill mix, workload • Availability and maintenance of equipment • Administrative and management support

11. Contributory Factor Analysis (cont.) • Organization/Management • Financial resources • Goals, policies, and standards • Safety culture and priorities • National/Public Health Factors • Economic and regulatory issues • Health policy and politics • Medical liability

12. Risk Analysis Matrix Simplified risk analysis matrix shows the relationship between severity of outcome of an event and likelihood of its reoccurrence. In general, events in the intermediate to high risk and moderate to severe severity are those which require active efforts to prevent or mitigate. Reason J. Human Error. 1990

13. Contributory Factor Analysis for This Case • Task Factors • Intubation task steps not explicit • No intubation protocol in place • Practitioner Factors • Inexperienced RN, did not know medications • Decreased attention of supervising MD • Verbal order—no briefing on roles/responsibilities

14. Contributory Factor Analysis for This Case (cont.) • Team Factors • Verbal order statement not complete • Inexperienced RN did not seek help • Team structure unclear • Working Conditions • RN shortage has led to increased hiring of younger, less experienced nurses • Inadequate training of nurses on high-risk units

15. Effective Team Work: The 5 “C’s” • Common Goal • Every team member shares the short- and long-term goals of the team/organization • Commitment • Every team member is committed to attaining the goals • Competence • Every team member has knowledge, skills, behaviors, and attitudes necessary to perform his or her role Katzenbach JR, Smith DK. The Wisdom of Teams. 1993.

16. Effective Team Work: The 5 “C’s” • Communication • Team members communicate effectively/efficiently with each other, the patient, and other parties • Coordination • Team members work together efficiently and effectively Katzenbach JR, Smith DK. The Wisdom of Teams. 1993.

17. Evidence for Communication Failures • Poor communication between team members accounted for 37% of all errors in a 4-month period of observation in critical units • Communication failures contributed to 16% (20/98) operating room events in anesthesia safety research • Almost 90% occur in last 2-4 hours of case Donchin Y, et al. Crit Care Med. 1995;23:294-300.

18. Evidence for Communication Failures (cont.) • During 700 hours of direct observation, communication errors accounted for 11% of 118 operating room events • At Dartmouth Hitchcock Medical Center, failures of team communication were identified in 61% of the 42 events reviewed over the past 4 years

19. Taxonomy of Communication Failures • Failure of message transmission • Failure of message reception • Failure of message acknowledgment

20. Failure of Message Transmission • Failure to inform • ICU doctor fails to inform anesthesiologist doing nasal intubation that patient is anticoagulated • Delayed transmission • Laboratory test results relevant to therapeutic decision “lost” for several hours

21. Failure of Message Transmission (cont.) • Wrong information transmitted • “Mrs. Jones had an MI” when it was in fact Mr. Smith • Ambiguous or incomplete information transmitted • Physician states “give rocuronium” without specifying dose, route, and/or timing

22. Failure of Message Reception • Message not heard • Noisy environment prevents team from hearing instructions • Wrong information heard • RN heard “give epinephrine” instead of “ephedrine” • Information misunderstood • Pharmacist thought order was for different patient • Failure to act on message • Distraction leads to delay or failure to give requested drug

23. Failure of Message Acknowledgment • Failure to acknowledge receipt • Anesthesiologist fails to acknowledge surgeon’s request that heparin be administered • Failure to acknowledge understanding • Team member responds with “uh-huh” rather than explicit read-back of instructions given • Failure to state when action taken • Requested action acknowledged, but either not taken or delayed and not stated when completed

24. Why do communication failures occur? • Current healthcare curricula largely fail to cover interpersonal influence, group dynamics, organizational behavior, negotiation, or conflict resolution • Care is provided by teams of individuals with diverse educational and cultural backgrounds • Non-verbal communication has strong influence • Up to 50% of “message” conveyed in non-verbal behavior (facial expression, body posture, movement, eye contact, etc.) Birdwhistell RL. Kinesics and Context. 1970. Mehrabian A. Silent Messages. 1981.

25. Key Components of Clinical Competence • Knowledge application • Problem-solving skills • Decision-making capacity • Effective communication • Team work • Adaptability Dreyfus HL, et al. Mind Over Machine. 1986.

26. Key Components of Clinical Competence • Situation awareness • Preparedness • Knowledge alone is not sufficient! Gaba DM, et al. Hum Factors. 1995;37:20-31.Endsley MR. Hum Factors. 1995;37:65-84.

27. Crew Resource Management (CRM) • Modality used in aviation industry to train team members applied to medicine • Anesthesia Crisis Resource Management Training (ACRM) • Uses high-fidelity patient simulation to recreate complexity of clinical care • Re-creates incidents that provoke performance failures in a safe environment • Videotapes analyzed later to identify performance failures and structure interventions Gaba DM, et al. Crisis Management in Anesthesiology. 1994.

28. Crew Resource Management (cont.) • Team members learn critical teamwork behaviors: • Task allocation • Read-backs • Closed-loop communication • Role clarification • Identifying individual responsibilities

29. Video Simulation • Video simulations demonstrate examples of both “miscommunication” and “good communication” • Click here to view videos online* • *You must be connected to the internet to see the videos

30. Take-Home Points • When evaluating medical errors, application of the Contributory Factor Analysis can prioritize problem areas and target resources for quality improvement efforts • Medical errors are increasingly due to failures in communication and teamwork • Effective teamwork requires the “5 C’s” • Common goal, Commitment, Competence, Communication, Coordination

31. Take-Home Points (cont.) • Traditional training models (lectures, tapes) are not sufficient to prevent these errors • Isolated training of different care provider types contributes to the difficulties in communication • CRM, video simulators, role-plays, other innovations will be needed to improve these areas