Tony Chang, MD Tuesday Conference September 6, 2005

1. Tony Chang, MD Tuesday Conference September 6, 2005

2. Crisis: A time of great danger or trouble whose outcome decides whether possible bad consequences will follow.

4. Other professions like ours: • Aviation • Spaceflight • Nuclear power and chemical manufacturing • Military Command – Fighter Pilots in combat • Fire fighting

5. Complex and Dynamic • Event driven and dynamic • Complex and tightly coupled • Uncertain • Risky

6. Dynamism Time pressure Intensity Complexity Uncertainty Risk What makes Anesthesia different from other specialties?

7. The stress of anesthesia

8. Anesthesiology, by its nature, involves crises The combination of complexity and dynamism makes crises much more likely to occur and more difficult to deal with.

9. Up to our elbows… • Anesthesia involves direct physical involvement in the tasks of patient care including: - performance of invasive procedures - administration of rapidly acting, potentially lethal medications - operation of increasingly complex devices

10. During crises, knowledge is not enough.. • Management of the environment, the equipment and the patient care team • This involves aspects of cognitive and social psychology, sociology and anthropology

11. Old View • Adequate Training + Qualified Trainee = Ability to handle Crisis Situations

12. New View • Each individual is affected by multiple factors…. • Individual strengths and vulnerabilities • Distractions, biases, errors • Environment, Equipment • Physiologic factors such as fatigue, emotional stress, illness

13. Error: Old vs New

14. It happened all of a sudden… • Crisis perceived as sudden in onset and rapid in development • In retrospect one can usually identify an evolution from underlying triggering events

15. Gaba DM, Fish KJ, Howard SK: Crisis Management in Anesthesia 1994

16. Triggering events may initiate a problem. A problem is an abnormal situation that requires attention but is unlikely by itself to cause harm. Problems can evolve and if not detected or corrected can lead to adverse outcomes.

17. Adverse Outcome…

18. The events that trigger problems do not occur at random • They emerge from three sets of underlying conditions: • Latent errors • Predisposing factors • Psychological precursors

19. 1. Latent Errors: …errors whose adverse consequences may lie dormant within the system for a long time, only becoming evident when they combine with other factors to breach the system’s defenses, most likely spawned by those whose activities are removed in space and time from direct control: designers, adminstrators, managers.

20. 2. Predisposing Factors: • The external environment constitutes predisposing factors. • In aviation this is weather. In anesthesia these are the patient’s underlying diseases and the nature of the surgery

21. 3. Psychological Precursors • Can predispose the surgeon or anesthesia provider to commit unsafe acts that may trigger a problem • “Performance Shaping Factors” including fatigue, boredom, illness, drugs, environment (noise, illumination)

23. Eliminating the Latent Factors • Most of the latent factors affecting anesthesia are too complex to analyze and find a single cause • Most effective strategy is targeted at individual cases including 1) the patient 2) the surgeon and anesthesia provider 3) the equipment

24. Complex Dynamic Worlds • Ill-structured problems • Uncertain dynamic environment • Time Stress • Shifting, ill-defined or competing goals • Action/feedback loops • High stakes • Multiple Players • Organizational goals and norms • Orasanu J, Conolly T: The reinvention of decision making, 1993, pp 3-20

25. Ambiguous Command Structure OR “team” is actually several “crews” Surgery, Anesthesiology, Nursing, Secretarial, Housekeeping Each Crew has its own command hierarchy and structure Sociology of the OR

26. “Expertise” in Anesthesia (or who would I choose to do MY anesthesia) • Intelligence + Motivation + anesthesia training = Expertise in anesthesia (?) • CME’s, Refresher Courses, M & M conferences – maintains “expertise” (?) • Is every “expert” then a good crisis manager?

27. Human Performance • The concept of “performance” is difficult to define • No “Gold Standard” • Difficult to measure • Data tends to be subjective

29. Critical Incidents in the OR

31. Elements of Core Mental Process • Observation • Verification • Problem Recognition • Prediction of future states • Decision-making • Action implementation • Reevaluation • Start again with observation

32. Problem Recognition • Matching sets of environmental cues to patterns that are known to represent specific types of problems • “Heuristics” – approximation strategies to handle ambiguous situations • Categorize into several “generic” problems, each with a differential • Frequency Gambling

33. Tasks • Primary tasks • Completion is dependent on Task Load • Secondary tasks • Completion is dependent on the priority of the Primary Task

34. Vigilance and Workload

35. Multi-Tasking in the OR

36. Prospective Memory • One’s ability to remember in the future to perform an action (i.e. restart the ventilator, administer medications, eye check) • Interruptions and “break-in-tasks” frequently delay or prevent • During a 3 hour period in the ED there were more than 30 interruptions and more than 20 breaks-in-task* Chisholm CD, Collison EK, Nelson DR, Cordell WH: Emergency department workplace interruptions:Are emergency physicians “interrupt-drive” and “multitasking”? Acad Emerg Med 7:1239-1243, 2000

37. Fixation Errors • The persistent failure to revise a diagnosis or plan in the face of readily available evidence that suggest a revision is necessary

38. 3 types of Fixation Errors • “This and only this!” • “Everything but this!” • “Everything is OK!”

39. “Perhaps the most insidious hazard of anesthesia is its relative safety. The individual anesthetist is rarely responsible for serious complications. It is our impressions that most seemingly minor errors are not taken seriously and risk management depends almost solely on the anesthetists ability to react instinctively and flawlessly Cooper JB, Newbower RS, Kitz RJ: An analysis of major errors and equipment failures in anesthesia management: Considerations for prevention and detection. Anesthesiology 60:34-42, 1984

40. Hazardous Attitudes

41. Production Pressure • 49% witnessed an event where patient safety was comprised due to pressure • 32% experienced strong pressure from surgeons to proceed with a case they wished to cancel • 20% responded, “sometimes I have altered my practices to hasten the start of a case”

42. Other complex worlds like ours • Military aviation – the desire to optimize human performance stems from the desire of the pilot to stay alive • Nuclear Power – Three Mile Island and Chernobyl • Chemical – Union Carbide plant, Bhopal India • Spaceflight – Space Shuttles Challenger and Columbia • Commerical aviation – learning from the lessons of military aviation, CRM training (based on the workshop, Management on the Flightdeck, sponsored by NASA 1979)

45. Anesthesia and Aviation

47. Vigilance… • Both Aviation and Anesthesia are describe as…”99% boredom and 1% Sheer Terror….”

48. 99% Boredom….

49. 1% Sheer Terror

50. Interesting Parallels • Preop Evaluation • Machine/Equipment check • Induction • Deepening Anesthesia • Intraop • Lightening Anesthesia • Emergence • Preflight • Aircraft and preflight checklist • Take Off • Gaining Altitude • Cruise Altitude • Descent • Landing