Discussion: role of human error in anaesthesia

Discussion: role of human error in anaesthesia ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Discussion: role of human error in anaesthesia I’m working on a Health & Medical exercise and need support. Discussion: role of human error in anaesthesia Students are assigned one weekly reading assignment (ten total) to include peer-reviewed seminal or breakthrough articles specific to the upcoming lecture. Students are required to summarize the findings of the article in a single page summary (one page +/- one paragraph, single-line spacing, 11pt font) and include a comment and/or question for discussion. The comment may include how materials relate to other course concepts or examples from your own life experience. The question may address any aspect of the paper including something that was confusing or about applying the material to different contexts. The completed assignments will be submitted before the lecture when the reading will be discussed (Sunday evening by 10pm). Full credit will be given for submitting on time with reasonable content (1 point), including both summary questions and/or comment (1 point), and meeting length requirements (1 point). A brief grace period of 30 minutes or less will apply in order to account for occasional technical difficulties in submitting work. Timely submission of work is important to keep pace with the course and to allow time to review grading feedback to guide maximum performance on subsequent work. Discussion: role of human error in anaesthesia hta_bja.pdf British Journal of Anaesthesia 100 (3): 333–43 (2008) doi:10.1093/bja/aem392 Advance Access publication January 31, 2008 Human factors in anaesthetic practice: insights from a task analysis D. Phipps1*, G. H. Meakin3, P. C. W. Beatty2, C. Nsoedo2 and D. Parker1 1 3 School of Psychological Sciences and 2School of Medicine, University of Manchester, Manchester, UK. University Department of Anaesthesia, Royal Manchester Children’s Hospital, Pendelbury, Manchester, UK *Corresponding author. School of Psychological Sciences, The University of Manchester, Room 124E, Zochonis Building, Brunswick Street, Manchester M13 9PL, UK. E-mail: [email protected] Background. Despite a growing recognition of the role of human error in anaesthesia, it remains unclear what should be done to mitigate its effects. We addressed this issue by using task analysis to create a systematic description of the behaviours that are involved during anaesthesia, which can be used as a framework for promoting good practice and highlight areas of concern. Methods. The task steps involved in preparing and delivering anaesthesia were identified using hierarchical task analysis (HTA). The systematic human error reduction and prediction approach (SHERPA) was then used to identify potential human errors at each task step and suggest ways of preventing these errors. Results. The number and type of behaviours involved vary according to the ‘phase’ of anaesthesia, with tasks in the induction room, including induction of anaesthesia itself, being the most demanding. Errors during preoperative planning and perioperative maintenance could be avoided by measures to support information handling and decision-making. Errors during machine checking, induction, and emergence could be reduced by streamlining or automating task steps, or by making changes to the physical design of the work environment. Conclusions. We have demonstrated the value of task analysis in improving anaesthetic practice. Task analysis facilitates the identification of relevant human factors issues and suggests ways in which these issues can be addressed. The output of the task analysis will be of use in focusing future interventions and research in this area. Br J Anaesth 2008; 100: 333–43 Keywords: ergonomics; human error; risk management; task analysis; training Accepted for publication: November 13, 2007 The adverse effect of human error on the safe and effective delivery of anaesthesia has been widely recognized for a number of years.1 – 5 However, what is not clear is how and when the different types of human error have an effect, or what steps can be taken to mitigate their effects. The aim of the study described in this paper is to address this question by using task analysis to create a detailed behavioural description of the anaesthetic process. Although particular aspects of anaesthetic practice will be highlighted for illustrative purposes, the emphasis of the paper is on demonstrating the use of task analysis to identify issues of potential concern rather than making firm recommendations about how the issues raised by the illustrative examples should be addressed. Task analysis has been described as a methodology for examining the actions or cognitive processes involved in a given work activity.6 In surgery, it has been shown to have the following benefits:7 † A human-centred description of the medical and surgical team activities, which in turn allows key skills and knowledge to be identified; † A means of identifying potential ‘vulnerabilities’ in the work processes, for example, gaps in procedures or interference from medical technologies; † An aid to defining suitable interventions to enhance work activity, including the specification of user and system requirements for technology-based solutions; Task analysis has also been used to study the activities in an intensive care unit, with the data subsequently being used as a baseline measure against which to identify and quantify errors.8 Another study examined a clinical # The Board of Management and Trustees of the British Journal of Anaesthesia 2008. All rights reserved. For Permissions, please e-mail: [email protected] Phipps et al. Discussion: role of human error in anaesthesiausing task analysis, and in doing so identified potential ‘bottlenecks’ within the pathway;9 for example, a task step that involved retrieval of an electronic patient record during patient admission was prone to error due to incorrect records being retrieved. Within anaesthesia, Weinger and colleagues10 have used task analysis to compare the performance of novice anaesthetists with those of experts. However, although it generates useful insights into anaesthetic practice, the approach of Weinger and colleagues focused more on the tasks themselves than on task behaviour. It involved an observer recording the frequency and duration of pre-defined clinical task activities, such as ‘i.v. adjustment’ and ‘conversing with surgeon’. Although this allows relevant activities to be identified, what appears to be less well captured in this technique is the sequence and organization of behaviours that make up the task activity. In the present study, the tasks involved in preparing and delivering anaesthesia were identified using hierarchical task analysis (HTA), as advocated by Ainsworth and Marshall.11 This begins with a general task goal (for example, ‘provide preoperative care’), and breaks this down, or ‘decomposes’ it, into the task steps that must be performed in order to achieve the main goal. The end result is a hierarchy of task steps that represent the behaviours that need to be performed in the conduct of a task. By way of illustration, an HTA of setting up an i.v. infusion is shown in Figure 1. The output of an HTA can be used in its own right as a self-contained description of task activity, but given that a major objective of this study was to identify potential Fig 1 A hierarchial task analysis of setting up an i.v. infusion, showing the initial decomposition (top) and then a further decomposition of one of the subgoals (bottom). human errors, we have employed an extension to HTA, known as the systematic human error reduction and prediction approach (SHERPA).12 This facilitates the identification of errors that could occur, and of the points during the task at which they might occur, by applying a classification of potential errors to the output of an HTA. The classification scheme lists a number of error types, from which the analyst selects those that are likely to apply to the task under consideration. Using the example shown in Figure 1, the errors listed in SHERPA that could credibly occur during task step 3.2 (‘check flow switches’) might be judged to include ‘check omitted’ and ‘wrong line checked’. Having identified the potential errors, each is examined further to determine its potential for occurring, the consequence of it occurring, and what could be done to reduce its occurrence. The advantage of SHERPA is that it is relatively straightforward and has a good level of reliability.13 Its use has recently been demonstrated to identify potential errors in the administration of medicines14 and in laparoscopic surgery.15 Methods Hierarchical task analysis The task analysis covered the anaesthetist’s main activities from the start of the preoperative visit to the postoperative handover of the patient to the recovery staff. Data were collected for the task analysis from the following sources. † Literature: In order to provide a theoretical background and ensure full coverage of anaesthetic practice, two anaesthetic textbooks16 17 and the AAGBI guidelines on preoperative machine checking18 were consulted and key anaesthetic tasks identified from these and organized into a timeline. † Observations: Having obtained institutional and NHS REC approval [Ethical approval for conduct in the NHS was granted by the Central Manchester Research Ethics Committee and the Salford and Trafford Local Research Ethics Committee (COREC project no. 06/Q1407/16)], two members of the research team (D.P. and C.N.) observed anaesthetic teams performing pre- and perioperative tasks at an adult teaching hospital and a paediatric specialist hospital. Discussion: role of human error in anaesthesia The researchers were present for several types of list at both hospitals, as listed in Table 1. In total, approximately 200 h of anaesthetic practice was observed, from which the researchers noted the behaviours that were carried out during performance of anaesthetic tasks. † Subject matter expert: Technical advice, and an initial review of the information gathered from the literature and observations, was provided by a member of the research team (G.H.M.). 334 A task analysis of anaesthetic practice Table 1 Operating lists observed at each study site Table 2 Error classifications used in SHERPA Site 1 (Paediatric) Site 2 (General teaching) Class of behaviour Type of error Cleft palate Gastroscopy General Orthopaedics Urology X-ray (cardiology catheters) Dental ENT General Gynaecology Maxillo-facial Plastics Trauma Urology Action Too long or too short Mistimed Wrong direction Too little/too much Misaligned Wrong object Wrong action Omitted Incomplete Wrong action and wrong object Omitted Incomplete Wrong object Wrong check Mistimed Wrong check, wrong object Information not obtained Wrong information obtained Information retrieval incomplete Information not communicated Wrong information communicated Information communication incomplete Omitted Wrong selection made Check The procedure adopted for carrying out the analysis followed the standard HTA process.19 20 This can be summarized as follows: 1. Identify the general task goal; 2. Identify the behavioural or cognitive steps that need to be combined in order to achieve the goal. These are known as the subordinate goals or subgoals; 3. Having identified the subgoals, define the circumstances under which each is carried out and the order in which they are conducted. This information is used to describe the plan for the overall goal; 4. Determine whether each subgoal needs to be decomposed into smaller steps; 5. If a subgoal needs to be decomposed, repeat the process from 2, with the subgoal now being treated as a goal; 6. Decomposition ends when a sufficient level of detail is reached. When this occurs is a matter of judgement, but as a rule of thumb, it is likely to be the point at which further decomposition of the subgoals is either impossible or will add little value given the objectives of the task analysis.19 In the current study, this was taken to be the point at which the subgoals describe specific interactive behaviours with the patient, equipment, or other staff. SHERPA The task steps at the lowest level of the HTA were examined in further detail using SHERPA. The procedure employed was that described by Stanton and colleagues,13 which is summarized as follows: 1. Classify the behaviour involved, from the following: action (e.g. pressing a button); retrieval (e.g. getting information); checking (e.g. conducting a procedural check); selection (e.g. choosing one alternative over another); information communication (e.g. talking to another party); 2. Using the classification of error types shown in Table 2, determine the errors that can credibly occur; 3. Describe the consequences of each error; 4. Determine the ‘recovery potential’ of each error, noting any steps that occur later in the HTA where the error Retrieval Communication Selection could be ‘recovered’ (i.e. identified and corrected before it has an effect); 5. Rate the probability of each error occurring, including instances where the error occurs but is ‘recovered’. Objective estimates for these values were not available in the literature and extracting them from available critical incident reports assumes that the error in question was always explicitly identified in the reports. The research team therefore agreed bands of likelihood from their own experience. These were ‘low’ (hardly ever occurs, 1 in 1000), ‘medium’ (occasionally occurs, .1 in 1000 but 1 in 100), and ‘high’ (frequently occurs, .1 in 100); 6. Rate the ‘criticality’ of each error—i.e. the potential for the error to lead to a critical incident if unchecked. Again, in the absence of objective data, the researchers were forced to use subjective bands based on their own experience. Discussion: role of human error in anaesthesia These were ‘low’ (a barely noticeable effect), ‘medium’ (a potentially noticeable but transient effect), and ‘high’ (a potentially life-threatening or permanent effect); 7. Suggest prospective remedial strategies to prevent each error from occurring or propagating (equipment, training, procedures, or organizational). The HTA and SHERPA were subsequently reviewed in toto by three subject matter experts who were not members of the research team. These included a surgical clinical research fellow with experience of task analysis (Mr S. K. Sarker, Royal Free Hospital, London), an academic human factors specialist (Prof. N. Stanton, Brunel 335 Phipps et al. University), and a professor of anaesthesia (Prof. J. M. Davies, University of Calgary), whose attention was drawn especially to the determination of probability and criticality of each error. Table 4 Extract from the HTA of perioperative care, showing the highest level task steps Task step Description Subordinate task steps 1 Carry out equipment checks 2 Prepare drugs 3 Identify patient 4 Attach essential monitors 5 Commence patient monitoring 6 Establish i.v. access 7 Administer anaesthetic 8 Secure patient’s airway Ensure oxygen analyser is present Check the supply of medical gases Check the operation of flowmeters Check the vaporizers Check the breathing system Check the ventilator Check the scavenging system Check ancillary system Check patient monitoring equipment Collect drug Determine the amount of drug required Transfer required amount to syringe Label syringe Check patient identification against case notes Confirm type of operation Attach pulse oximeter Attach arterial pressure monitor Attach ECG monitor Attach gas/agent monitor Monitor oxygen saturation Monitor arterial pressure Monitor heart rate and rhythm Monitor respiration and respiratory gas traces Clean skin at cannulation site Insert cannula Commence i.v. fluid administration Administer oxygen at 100% concentration Administer hypnotic drug Administer inhalation agent Administer analgesic drug Administer neuromuscular blocking agent drug Monitor inhalation agent Adjust anaesthetic concentration Insert oral airway Insert laryngeal mask airway Insert tracheal tube Insert throat pack Fix airway 9 10 Cover patient’s eyes Attach additional monitors (if required) 11 Commence additional monitoring 12 Transfer to operating room Results An overview of the HTA output is shown in Tables 3 and 4, showing the highest-level task steps for preoperative care and perioperative care, respectively. Owing to the amount of detail generated by the HTA and SHERPA, only selected extracts, shown in Table 4, will be discussed. The extracts were chosen because they illustrate the use of task analysis, not because we judged them to be any more important from an anaesthetic point of view. They are discussed in relation to phases of giving an anaesthetic that would be recognizable to anaesthetists, namely: † preoperative planning (Table 2); † tasks in the induction room, including: W preoperative equipment check (task 1, Table 3); W preparation of drugs (task 2, Table 3); W commencing essential patient monitoring (tasks 4 and 5, Table 3); W induction of anaesthesia (tasks 6, 7, and 8, Table 3). † transfer of the patient to the operating theatre (task 12, Table 3); † maintenance of anaesthesia (task 13, Table 3); † emergence from anaesthesia (tasks 14 and 15, Table 3). A complete account of the results is available from the first author. Table 3 Extract from the HTA of preoperative care, showing the highest level task steps Task step Description Subordinate task steps 1 Assess patient Assess surgical procedure Assess medical history Perform physical examination Decide whether to give premedication Prescribe premedication Request full blood count Request urea and electrolytes Request coagulation tests Request chest radiography Request ECG Request sickle test Request urinalysis Choose anaesthetic drugs Choose delivery method Decide on postoperative care Agree choices with patient 2 3 4 Request investigations (if required) Decide on anaesthetic to be used Reassure patient Attach temperature probe Attach peripheral nerve stimulator Insert/attach invasive monitoring Monitor temperature of patient Monitor degree of neuromuscular block Monitor output of invasive monitors Remove i.v. infusion set Disconnect monitoring lines Check lines on patient are secure Continued 336 A task analysis of anaesthetic practice Table 4 Continued Task step Description 13 Maintain anaesthesia 14 Discontinue anaesthesia 15 Transfer to recovery room 16 Complete documentation Subordinate task steps Move trolley into theatre Move patient from trolley to operating table Connect monitoring lines to monitors Recommence i.v. infusion Monitor condition Adjust anaesthetic concentration Review/amend postoperative requirements Inform recovery nurse of requirements Discontinue drug administration Administer reversal drugs Administer oxygen at 100% concentration Uncover patient’s eyes Remove artificial airway Continue oxygen administration Discontinue i.v. fluid administration Disconnect monitors Move patient from operating table onto trolley Place patient in left lateral position Move trolley into recovery room Handover to recovery nurse Check details on anaesthetic chart Check postoperative care instructions File documentation. Discussion: role of human error in anaesthesia Preoperative planning Preoperative planning is an activity consisting mainly of information gathering and decision-making, and it relies on both communication with patients and on liaison with other members of staff. For example, the anaesthetist often relies on surgeons providing accurate details about the operation, or on laboratory staff in performing tests that he or she requests. In such situations, the physical, technical, and interpersonal separation between different staff roles may hamper effective collaborative working.21 22 Given the amount of data handling during preoperative care, another issue that may be of interest is whether technological support could be of assistance during this phase, for example, by providing access to electronic patient records. Tasks in the induction room The equipment check is largely a process of examining and operating various parts of the anaesthetic equipment to confirm that they are serviceable. However, with 44 task steps, the equipment check is a potentially lengthy and detailed process, and it is possible that steps may be omitted, either intentionally or unintentionally. Although the process might be guided by a checklist, another option, which has become a reality on some new models of anaesthetic machine, is for the process to be partly or fully automated. Two particular human factors problems were identified during the analysis. The first was the potential for errors to arise due to an incorrect configuration of the ventilator tubing being missed during the machine check. This appears to be especially likely when an unfamiliar machine is in use; hence, a basic precaution is for those responsible for machine checking to ensure that they are familiar with the different types of machine available at the hospital in question. Some anaesthetic departments have taken the fundamental measure of standardizing the types of machines they procure. The second problem identified was that of the common gas outlet control; on some types of anaes … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10