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MODELING AND ERRORS

MODELING AND ERRORS. Unweaving the Rainbow of Surgery A New Way of Communication. Overview. Accident is a catastrophic expressions of human error. Surgery has evolved into a technically complex endeavor that invites human error and system failure.

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MODELING AND ERRORS

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  1. MODELING AND ERRORS • Unweaving the Rainbow of Surgery • A New Way of Communication James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  2. Overview • Accident is a catastrophic expressions of human error. • Surgery has evolved into a technically complex endeavor that invites human error and system failure. • Surgery is a definable and measurable process • Errors occur within the CONTEXT of a particular operation’s defined process and sub processes. • Engineering tools (IDEF0) to analyze processes in complex systems can help us define, understand, and control error. James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  3. Nomenclature of Errors • Error will be taken as a generic term to encompass all those occasions in which a planned sequence of mental or physical activities fails to achieve its intended outcome, and when these failures cannot be attributed to the intervention of some chance agency. • Intended • knowledge-base mistakes • rule-based mistakes • violations • Unintended • slips • lapses James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU (Mandler, 1975; Woods, 1984)

  4. Surgery Progressed from a Primitive Art to Technical Endeavor James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  5. James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  6. “Factory Physics” James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  7. Definition of Surgery • Surgery is a process that physically alters the patient’s anatomy through excision, reconstruction, implantation, etc. in order to diagnosis and treat. • The surgical process transforms the patient’s physiological state to a more advantageous situation (state) for healing, function, cosmesis and the relief of suffering James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU (Bauer, 2003)

  8. IDEF0 • Integrated DEFinition language 0 • Ideal for representing processes & functions • Graphical modeling language • Boxes: functions • Arrows: relationships • Represents any level of abstraction • “Big picture” • Fine details • Depicts concurrency, functional dependencies (not sequences) James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  9. Surgical Goal Patient Factors Surgical Sys Factors 4 Ps (Philosophy, Policies, Procedures, Practices) Recovering Patient Patient PERFORM SURGERY OR to be Cleaned & Restock OR Ready Surgical Specimens & Waste Documentation Finished Documentation Ready OR Team Surgeon Anesthetist Nursing James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  10. IDEF0 Conventions Controls: things that define the goal or/and guide, facilitate, or constrain the function Surgical Goal Patient Factors Surgical Sys Factors Function: a goal directed process 4 Ps (Philosophy, Policies, Procedures, Practices) Recovering Patient Patient PERFORM SURGERY OR to be Cleaned & Restock OR Ready Surgical Specimens & Waste Documentation Finished Documentation Inputs: systems and other things that are changed by the function Outputs: the results of performing the function Ready OR Team Mechanisms: actors (humans or machines) that perform the function James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  11. Perform Laparoscopic Hysterectomy Prepare OR Restore Surgical Prepare Patient Initiate Patient Plan Surgery System for Perform Surgery System to Neutral for Surgery Recovery Surgery State Perform Surgical Support OR Manage Patient’s Manage Patient’s Configure OR Procedure Functions Position Physiology Create & Plan & Assess Prepare Maintain Perform Surgical Anatomic Site Exit Site & Region Close Patient Surgical Procedure Procedure for Procedure Workspace Document Plan and Assess Insert Primary Insufflate Insert & Mange Insert Secondary Workspace Workspace Trocar Abdomen Laparoscope Trocar Findings Insert Open Secure Trocar Connect Light Maintain Clear Plan & Assess Insert Blunt Manage Laparoscope Abdominal Wall Sleeve to Source & Orient Camera View of Primary Trocar Laparoscope into Trocar for Primary Abdominal Camera Workspace Trocar Sleeve Trocar Wall Maintain Select Sites Incision for Push Plan & Assess Prepare Control Plan & Assess Secure Tubing Internal for Secondary Secondary Secondary Secondary Secondary Insufflator Insufflation to Trocar Surgical Trocar in Trocar Trocar Trocar System Trocar Space IDEF0 HIERCHY James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  12. Perform Perform Laparoscopic Laparoscopic Hysterectomy Hysterectomy Prepare OR Prepare OR Restore Surgical Restore Surgical Prepare Patient Prepare Patient Initiate Patient Initiate Patient Plan Surgery Plan Surgery System for System for Perform Surgery Perform Surgery System to Neutral System to Neutral for Surgery for Surgery Recovery Recovery Surgery Surgery State State Perform Surgical Perform Surgical Support OR Support OR Manage Patient’s Manage Patient’s Manage Patient’s Manage Patient’s Configure OR Configure OR Procedure Procedure Functions Functions Position Position Physiology Physiology Create & Create & Plan & Assess Plan & Assess Prepare Prepare Maintain Maintain Perform Perform Surgical Surgical Anatomic Site Anatomic Site Exit Site & Region Exit Site & Region Close Patient Close Patient Surgical Surgical Procedure Procedure Procedure Procedure for Procedure for Procedure Workspace Workspace Document Document Plan and Assess Plan and Assess Insert Primary Insert Primary Insufflate Insufflate Insert & Mange Insert & Mange Insert Secondary Insert Secondary Workspace Workspace Workspace Workspace Trocar Trocar Abdomen Abdomen Laparoscope Laparoscope Trocars Trocars Findings Findings Insert Insert Open Open Secure Trocar Secure Trocar Connect Light Connect Light Maintain Clear Maintain Clear Plan & Assess Plan & Assess Insert Blunt Insert Blunt Manage Manage Laparoscope Laparoscope Abdominal Wall Abdominal Wall Sleeve to Sleeve to Source & Source & Orient Camera Orient Camera View of View of Primary Primary Trocar Trocar Laparoscope Laparoscope into Trocar into Trocar for Primary for Primary Abdominal Abdominal Camera Camera Workspace Workspace Trocar Trocar Sleeve Sleeve Trocar Trocar Wall Wall Maintain Maintain Select Sites Select Sites Incision for Incision for Push Push Plan & Assess Plan & Assess Prepare Prepare Control Control Plan & Assess Plan & Assess Secure Tubing Secure Tubing Internal Internal for Secondary for Secondary Secondary Secondary Secondary Secondary Secondary Secondary Secondary Secondary Insufflator Insufflator Insufflation Insufflation to Trocar to Trocar Surgical Surgical Trocar in Trocar in Trocar Trocar Trocar Trocar Trocar Trocar System System Trocar Trocar Space Space IDEF0 HIERCHY James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  13. IDEF0 (A0) James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  14. Perform Perform Laparoscopic Laparoscopic Hysterectomy Hysterectomy Prepare OR Prepare OR Restore Surgical Restore Surgical Prepare Patient Prepare Patient Initiate Patient Initiate Patient Plan Surgery Plan Surgery System for System for Perform Surgery Perform Surgery System to Neutral System to Neutral for Surgery for Surgery Recovery Recovery Surgery Surgery State State Perform Surgical Perform Surgical Support OR Support OR Manage Patient’s Manage Patient’s Manage Patient’s Manage Patient’s Configure OR Configure OR Procedure Procedure Functions Functions Position Position Physiology Physiology Create & Create & Plan & Assess Plan & Assess Prepare Prepare Maintain Maintain Perform Perform Surgical Surgical Anatomic Site Anatomic Site Exit Site & Region Exit Site & Region Close Patient Close Patient Surgical Surgical Procedure Procedure Procedure Procedure for Procedure for Procedure Workspace Workspace Document Document Plan and Assess Plan and Assess Insert Primary Insert Primary Insufflate Insufflate Insert & Mange Insert & Mange Insert Secondary Insert Secondary Workspace Workspace Workspace Workspace Trocar Trocar Abdomen Abdomen Laparoscope Laparoscope Trocars Trocars Findings Findings Insert Insert Open Open Secure Trocar Secure Trocar Connect Light Connect Light Maintain Clear Maintain Clear Plan & Assess Plan & Assess Insert Blunt Insert Blunt Manage Manage Laparoscope Laparoscope Abdominal Wall Abdominal Wall Sleeve to Sleeve to Source & Source & Orient Camera Orient Camera View of View of Primary Primary Trocar Trocar Laparoscope Laparoscope into Trocar into Trocar for Primary for Primary Abdominal Abdominal Camera Camera Workspace Workspace Trocar Trocar Sleeve Sleeve Trocar Trocar Wall Wall Maintain Maintain Select Sites Select Sites Incision for Incision for Push Push Plan & Assess Plan & Assess Prepare Prepare Control Control Plan & Assess Plan & Assess Secure Tubing Secure Tubing Internal Internal for Secondary for Secondary Secondary Secondary Secondary Secondary Secondary Secondary Secondary Secondary Insufflator Insufflator Insufflation Insufflation to Trocar to Trocar Surgical Surgical Trocar in Trocar in Trocar Trocar Trocar Trocar Trocar Trocar System System Trocar Trocar Space Space IDEF0 HIERCHY James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  15. IDEF0 (A4) James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  16. Perform Perform Laparoscopic Laparoscopic Hysterectomy Hysterectomy Prepare OR Prepare OR Restore Surgical Restore Surgical Prepare Patient Prepare Patient Initiate Patient Initiate Patient Plan Surgery Plan Surgery System for System for Perform Surgery Perform Surgery System to Neutral System to Neutral for Surgery for Surgery Recovery Recovery Surgery Surgery State State Perform Surgical Perform Surgical Support OR Support OR Manage Patient’s Manage Patient’s Manage Patient’s Manage Patient’s Configure OR Configure OR Procedure Procedure Functions Functions Position Position Physiology Physiology Create & Create & Plan & Assess Plan & Assess Prepare Prepare Maintain Maintain Perform Perform Surgical Surgical Anatomic Site Anatomic Site Exit Site & Region Exit Site & Region Close Patient Close Patient Surgical Surgical Procedure Procedure Procedure Procedure for Procedure for Procedure Workspace Workspace Document Document Plan and Assess Plan and Assess Insert Primary Insert Primary Insufflate Insufflate Insert & Mange Insert & Mange Insert Secondary Insert Secondary Workspace Workspace Workspace Workspace Trocar Trocar Abdomen Abdomen Laparoscope Laparoscope Trocars Trocars Findings Findings Insert Insert Open Open Secure Trocar Secure Trocar Connect Light Connect Light Maintain Clear Maintain Clear Plan & Assess Plan & Assess Insert Blunt Insert Blunt Manage Manage Laparoscope Laparoscope Abdominal Wall Abdominal Wall Sleeve to Sleeve to Source & Source & Orient Camera Orient Camera View of View of Primary Primary Trocar Trocar Laparoscope Laparoscope into Trocar into Trocar for Primary for Primary Abdominal Abdominal Camera Camera Workspace Workspace Trocar Trocar Sleeve Sleeve Trocar Trocar Wall Wall Maintain Maintain Select Sites Select Sites Incision for Incision for Push Push Plan & Assess Plan & Assess Prepare Prepare Control Control Plan & Assess Plan & Assess Secure Tubing Secure Tubing Internal Internal for Secondary for Secondary Secondary Secondary Secondary Secondary Secondary Secondary Secondary Secondary Insufflator Insufflator Insufflation Insufflation to Trocar to Trocar Surgical Surgical Trocar in Trocar in Trocar Trocar Trocar Trocar Trocar Trocar System System Trocar Trocar Space Space IDEF0 HIERCHY James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  17. IDEF0 (A45) surg proc goal Pt factors surg proc 4Ps surg proc subgoals OR Sys factors Pt: workspace maintained site goal workspace goal proc goal close goal exit goal req for Pt pos req for Pt phys plan & assess 1 surg tools & matls: ready to use create & OR Sys: configured maintain Pt: managed workspace surg docs: open 2 req for OR config A452 req for tools & matls prep anatomic surg tools & matls: used site 3 OR Sys: used perform surg docs: updated procedure 4 surgical specimens exit site & region waste 5 close Pt 6 James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU Pt: surgery performed S FA Pt: proc completed Pt: site prepped Pt: site exited

  18. Perform Perform Laparoscopic Laparoscopic Hysterectomy Hysterectomy Prepare OR Prepare OR Restore Surgical Restore Surgical Prepare Patient Prepare Patient Initiate Patient Initiate Patient Plan Surgery Plan Surgery System for System for Perform Surgery Perform Surgery System to Neutral System to Neutral for Surgery for Surgery Recovery Recovery Surgery Surgery State State Perform Surgical Perform Surgical Support OR Support OR Manage Patient’s Manage Patient’s Manage Patient’s Manage Patient’s Configure OR Configure OR Procedure Procedure Functions Functions Position Position Physiology Physiology Create & Create & Plan & Assess Plan & Assess Prepare Prepare Maintain Maintain Perform Perform Surgical Surgical Anatomic Site Anatomic Site Exit Site & Region Exit Site & Region Close Patient Close Patient Surgical Surgical Procedure Procedure Procedure Procedure for Procedure for Procedure Workspace Workspace Document Document Plan and Assess Plan and Assess Insert Primary Insert Primary Insufflate Insufflate Insert & Mange Insert & Mange Insert Secondary Insert Secondary Workspace Workspace Workspace Workspace Trocar Trocar Abdomen Abdomen Laparoscope Laparoscope Trocars Trocars Findings Findings Insert Insert Open Open Secure Trocar Secure Trocar Connect Light Connect Light Maintain Clear Maintain Clear Plan & Assess Plan & Assess Insert Blunt Insert Blunt Manage Manage Laparoscope Laparoscope Abdominal Wall Abdominal Wall Sleeve to Sleeve to Source & Source & Orient Camera Orient Camera View of View of Primary Primary Trocar Trocar Laparoscope Laparoscope into Trocar into Trocar for Primary for Primary Abdominal Abdominal Camera Camera Workspace Workspace Trocar Trocar Sleeve Sleeve Trocar Trocar Wall Wall Maintain Maintain Select Sites Select Sites Incision for Incision for Push Push Plan & Assess Plan & Assess Prepare Prepare Control Control Plan & Assess Plan & Assess Secure Tubing Secure Tubing Internal Internal for Secondary for Secondary Secondary Secondary Secondary Secondary Secondary Secondary Secondary Secondary Insufflator Insufflator Insufflation Insufflation to Trocar to Trocar Surgical Surgical Trocar in Trocar in Trocar Trocar Trocar Trocar Trocar Trocar System System Trocar Trocar Space Space IDEF0 HIERCHY James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  19. IDEF0 (A452) James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  20. Perform Perform Laparoscopic Laparoscopic Hysterectomy Hysterectomy Prepare OR Prepare OR Restore Surgical Restore Surgical Prepare Patient Prepare Patient Initiate Patient Initiate Patient Plan Surgery Plan Surgery System for System for Perform Surgery Perform Surgery System to Neutral System to Neutral for Surgery for Surgery Recovery Recovery Surgery Surgery State State Perform Surgical Perform Surgical Support OR Support OR Manage Patient’s Manage Patient’s Manage Patient’s Manage Patient’s Configure OR Configure OR Procedure Procedure Functions Functions Position Position Physiology Physiology Create & Create & Plan & Assess Plan & Assess Prepare Prepare Maintain Maintain Perform Perform Surgical Surgical Anatomic Site Anatomic Site Exit Site & Region Exit Site & Region Close Patient Close Patient Surgical Surgical Procedure Procedure Procedure Procedure for Procedure for Procedure Workspace Workspace Document Document Plan and Assess Plan and Assess Insert Primary Insert Primary Insufflate Insufflate Insert & Mange Insert & Mange Insert Secondary Insert Secondary Workspace Workspace Workspace Workspace Trocar Trocar Abdomen Abdomen Laparoscope Laparoscope Trocars Trocars Findings Findings Insert Insert Open Open Secure Trocar Secure Trocar Connect Light Connect Light Maintain Clear Maintain Clear Plan & Assess Plan & Assess Insert Blunt Insert Blunt Manage Manage Laparoscope Laparoscope Abdominal Wall Abdominal Wall Sleeve to Sleeve to Source & Source & Orient Camera Orient Camera View of View of Primary Primary Trocar Trocar Laparoscope Laparoscope into Trocar into Trocar for Primary for Primary Abdominal Abdominal Camera Camera Workspace Workspace Trocar Trocar Sleeve Sleeve Trocar Trocar Wall Wall Maintain Maintain Select Sites Select Sites Incision for Incision for Push Push Plan & Assess Plan & Assess Prepare Prepare Control Control Plan & Assess Plan & Assess Secure Tubing Secure Tubing Internal Internal for Secondary for Secondary Secondary Secondary Secondary Secondary Secondary Secondary Secondary Secondary Insufflator Insufflator Insufflation Insufflation to Trocar to Trocar Surgical Surgical Trocar in Trocar in Trocar Trocar Trocar Trocar Trocar Trocar System System Trocar Trocar Space Space IDEF0 HIERCHY James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  21. IDEF0 (A4522) James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  22. Perform Perform Laparoscopic Laparoscopic Hysterectomy Hysterectomy Prepare OR Prepare OR Restore Surgical Restore Surgical Prepare Patient Prepare Patient Initiate Patient Initiate Patient Plan Surgery Plan Surgery System for System for Perform Surgery Perform Surgery System to Neutral System to Neutral for Surgery for Surgery Recovery Recovery Surgery Surgery State State Perform Surgical Perform Surgical Support OR Support OR Manage Patient’s Manage Patient’s Manage Patient’s Manage Patient’s Configure OR Configure OR Procedure Procedure Functions Functions Position Position Physiology Physiology Create & Create & Plan & Assess Plan & Assess Prepare Prepare Maintain Maintain Perform Perform Surgical Surgical Anatomic Site Anatomic Site Exit Site & Region Exit Site & Region Close Patient Close Patient Surgical Surgical Procedure Procedure Procedure Procedure for Procedure for Procedure Workspace Workspace Document Document Plan and Assess Plan and Assess Insert Primary Insert Primary Insufflate Insufflate Insert & Mange Insert & Mange Insert Secondary Insert Secondary Workspace Workspace Workspace Workspace Trocar Trocar Abdomen Abdomen Laparoscope Laparoscope Trocars Trocars Findings Findings Insert Insert Open Open Secure Trocar Secure Trocar Connect Light Connect Light Maintain Clear Maintain Clear Plan & Assess Plan & Assess Insert Blunt Insert Blunt Manage Manage Laparoscope Laparoscope Abdominal Wall Abdominal Wall Sleeve to Sleeve to Source & Source & Orient Camera Orient Camera View of View of Primary Primary Trocar Trocar Laparoscope Laparoscope into Trocar into Trocar for Primary for Primary Abdominal Abdominal Camera Camera Workspace Workspace Trocar Trocar Sleeve Sleeve Trocar Trocar Wall Wall Maintain Maintain Select Sites Select Sites Incision for Incision for Push Push Plan & Assess Plan & Assess Prepare Prepare Control Control Plan & Assess Plan & Assess Secure Tubing Secure Tubing Internal Internal for Secondary for Secondary Secondary Secondary Secondary Secondary Secondary Secondary Secondary Secondary Insufflator Insufflator Insufflation Insufflation to Trocar to Trocar Surgical Surgical Trocar in Trocar in Trocar Trocar Trocar Trocar Trocar Trocar System System Trocar Trocar Space Space IDEF0 HIERCHY James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  23. IDEF0 (A4523) James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  24. Perform Perform Laparoscopic Laparoscopic Hysterectomy Hysterectomy Prepare OR Prepare OR Restore Surgical Restore Surgical Prepare Patient Prepare Patient Initiate Patient Initiate Patient Plan Surgery Plan Surgery System for System for Perform Surgery Perform Surgery System to Neutral System to Neutral for Surgery for Surgery Recovery Recovery Surgery Surgery State State Perform Surgical Perform Surgical Support OR Support OR Manage Patient’s Manage Patient’s Manage Patient’s Manage Patient’s Configure OR Configure OR Procedure Procedure Functions Functions Position Position Physiology Physiology Create & Create & Plan & Assess Plan & Assess Prepare Prepare Maintain Maintain Perform Perform Surgical Surgical Anatomic Site Anatomic Site Exit Site & Region Exit Site & Region Close Patient Close Patient Surgical Surgical Procedure Procedure Procedure Procedure for Procedure for Procedure Workspace Workspace Document Document Plan and Assess Plan and Assess Insert Primary Insert Primary Insufflate Insufflate Insert & Mange Insert & Mange Insert Secondary Insert Secondary Workspace Workspace Workspace Workspace Trocar Trocar Abdomen Abdomen Laparoscope Laparoscope Trocars Trocars Findings Findings Insert Insert Open Open Secure Trocar Secure Trocar Connect Light Connect Light Maintain Clear Maintain Clear Plan & Assess Plan & Assess Insert Blunt Insert Blunt Manage Manage Laparoscope Laparoscope Abdominal Wall Abdominal Wall Sleeve to Sleeve to Source & Source & Orient Camera Orient Camera View of View of Primary Primary Trocar Trocar Laparoscope Laparoscope into Trocar into Trocar for Primary for Primary Abdominal Abdominal Camera Camera Workspace Workspace Trocar Trocar Sleeve Sleeve Trocar Trocar Wall Wall Maintain Maintain Select Sites Select Sites Incision for Incision for Push Push Plan & Assess Plan & Assess Prepare Prepare Control Control Plan & Assess Plan & Assess Secure Tubing Secure Tubing Internal Internal for Secondary for Secondary Secondary Secondary Secondary Secondary Secondary Secondary Secondary Secondary Insufflator Insufflator Insufflation Insufflation to Trocar to Trocar Surgical Surgical Trocar in Trocar in Trocar Trocar Trocar Trocar Trocar Trocar System System Trocar Trocar Space Space IDEF0 HIERCHY James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  25. IDEF0 (A4524) James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  26. Perform Perform Laparoscopic Laparoscopic Hysterectomy Hysterectomy Prepare OR Prepare OR Restore Surgical Restore Surgical Prepare Patient Prepare Patient Initiate Patient Initiate Patient Plan Surgery Plan Surgery System for System for Perform Surgery Perform Surgery System to Neutral System to Neutral for Surgery for Surgery Recovery Recovery Surgery Surgery State State Perform Surgical Perform Surgical Support OR Support OR Manage Patient’s Manage Patient’s Manage Patient’s Manage Patient’s Configure OR Configure OR Procedure Procedure Functions Functions Position Position Physiology Physiology Create & Create & Plan & Assess Plan & Assess Prepare Prepare Maintain Maintain Perform Perform Surgical Surgical Anatomic Site Anatomic Site Exit Site & Region Exit Site & Region Close Patient Close Patient Surgical Surgical Procedure Procedure Procedure Procedure for Procedure for Procedure Workspace Workspace Document Document Plan and Assess Plan and Assess Insert Primary Insert Primary Insufflate Insufflate Insert & Mange Insert & Mange Insert Secondary Insert Secondary Workspace Workspace Workspace Workspace Trocar Trocar Abdomen Abdomen Laparoscope Laparoscope Trocars Trocars Findings Findings Insert Insert Open Open Secure Trocar Secure Trocar Connect Light Connect Light Maintain Clear Maintain Clear Plan & Assess Plan & Assess Insert Blunt Insert Blunt Manage Manage Laparoscope Laparoscope Abdominal Wall Abdominal Wall Sleeve to Sleeve to Source & Source & Orient Camera Orient Camera View of View of Primary Primary Trocar Trocar Laparoscope Laparoscope into Trocar into Trocar for Primary for Primary Abdominal Abdominal Camera Camera Workspace Workspace Trocar Trocar Sleeve Sleeve Trocar Trocar Wall Wall Maintain Maintain Select Sites Select Sites Incision for Incision for Push Push Plan & Assess Plan & Assess Prepare Prepare Control Control Plan & Assess Plan & Assess Secure Tubing Secure Tubing Internal Internal for Secondary for Secondary Secondary Secondary Secondary Secondary Secondary Secondary Secondary Secondary Insufflator Insufflator Insufflation Insufflation to Trocar to Trocar Surgical Surgical Trocar in Trocar in Trocar Trocar Trocar Trocar Trocar Trocar System System Trocar Trocar Space Space IDEF0 HIERCHY James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  27. IDEF0 (A4525) James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  28. Common Bile Duct Accident IDEFO Analysis of a Cascade of Errors (Thanks & Appreciation to Dr. Rosser & Dr. Vazquez)

  29. Laparoscopic Cholecystectomy IDEF0 Node Tree James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  30. Creating Surgical Workspace via Laparoscopy James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  31. Recommended Configuration for Operative Port Placement James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  32. Film Location of Third Port Should be Lateral & Inferior in Relation to Port #2 Incorrect Third Port Placement James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  33. Manage Laparoscope Video Image James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  34. Where the Mistakes Arise: Cognitive Processing James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  35. Video GB Infundibulum is Pulled Medial as Opposed to Lateral Distorted Biliary Anatomy Landmarks Difficult to Locate & Identify Anticipated Anatomic Relationships Altered Incorrect Application of Retraction Forces Upon GB & Biliary Tree James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  36. James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  37. Disorientation & Cognitive Confusion: A Flawed Beginning James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  38. Use 30 degree scope Lateral and cephalad retraction of fundus Lateral and inferior retraction of infundibulum Hunter’s Recommendations “Disorientation Countermeasures” James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  39. video In the surgeon’s minds eye, the perceived situation is Normal Despite Altered Relationships Despite Clues to the contrary The proceeds according to a rigid plan Cognitive Fixation James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  40. There should be adequate exposure of the junction of Hartmann’s pouch and the cystic duct Always identify the junction between the common bile duct and the cystic duct No structure should be divided until it is clearly identified Violation of Hunter’s Rules James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  41. Endpoint -- Division of the CBD • video James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  42. Operative cholangiography should be routine James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  43. Rasmussen’s Model of Accident Causation The Swiss cheese model of how defenses, barriers, and safeguards may be penetrated by an accident trajectory. Reason J. BMJ 2000 James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

  44. Scientific Modeling and ThoughtTheodoric of Freiburg“The first Unweaving of the Rainbow” James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU James D. Bauer MDSamaritan Health ServicesAsst. Professor OB & GYN OHSU James Burke (1995)

  45. Epiphany • Engineering & Military Aviation • Medicine & Surgery James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, OHSU

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