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The Human Factor – Finessing the White Bears Alan Merry Professor and HOD Anaesthesiology University of Auckland. Disclosure. Alan Merry has financial interests in Safer Sleep LLC Is on the Boards of Safer Sleep LLC NZ Health Quality and Safety Commission Lifebox

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Presentation Transcript
slide1

The Human Factor – Finessing the White Bears

Alan Merry

Professor and HOD Anaesthesiology

University of Auckland

slide2

Disclosure

  • Alan Merry has financial interests in
  • Safer Sleep LLC
  • Is on the Boards of
  • Safer Sleep LLC
  • NZ Health Quality and Safety Commission
  • Lifebox
  • ANZCA (ie as a Councillor)
  • and has received support for research from
  • ANZCA
  • WHO
  • HRC NZ
  • AFT Pharmaceuticals
  • Roche Baxter
  • and others
today
Today…
  • A story of an error in anaesthesia
  • Systems, human error and why things go wrong, extending the Reason model with some new ideas
  • Some recent guidelines and

possible solutions

  • Acknowledge Atul Gawande, Angela Enright, Iain Wilson, Rob McDougal, Peter Kempthorne and others
medication errors in anaesthesia
Medication Errors in Anaesthesia
  • About 1 in every 1000 administrations (≈135 anaesthetics)
  • 10 000 drug errors reported in the UK in 2006

25 deaths and 28 cases of severe harm

Webster Merry et al Anaesth Intens Care 2001

NPSA “Promoting safer use of injectable medicines” 2007

approaches to cognitive psychology
Approaches to Cognitive Psychology
  • Experimental cognitive psychology
    • experiments on healthy individuals
  • Cognitive neuropsychology
    • studying impairment in brain damage
  • Computational cognitive science
    • modelling
  • Cognitive neuroscience
    • imaging
errors
Errors
  • Experts make errors
  • Not carelessness
  • Deterrence useless
  • Medical practice is challenging
slide12

Errors - Definition

  • When you are trying to do the right thing but you actually do the wrong thing
  • Focus on process not outcome
violations
Violations
  • Element of choice
  • May be carelessness
  • Deterrence may be effective
violations1
Violations
  • Element of choice
  • May be carelessness
  • Deterrence may be effective
  • Not always reprehensible
  • Systems double-bind
classification of error
Classification of Error
  • Action failure
    • Skill-based (slips and lapses)
    • Technical (dural tap)
  • Decision or planning failure
    • Rule-based
    • Knowledge-based
classification of error1
Classification of Error
  • Action failure
    • Skill-based (slips and lapses)
    • Technical (dural tap)
  • Decision or planning failure
    • Rule-based
    • Knowledge-based Errors of reasoning
chaos theory deterministic vs random systems
Chaos Theory:Deterministic vs Random Systems

Predictability:

Does the Flap of a Butterfly’s Wings in Brazil set off a Tornado in Texas?

Lorenz E American Association for the Advancement of Science 1972

http://en.wikipedia.org/wiki/File:Edward_lorenz.jpg

problems
Problems
  • Simple ( baking a cake)
  • Complicated (going to the moon)
  • Complex (raising a child)

Zimmerman and Glouberman

Cited in GawandeThe Checklist Manifesto 2010

how we think1
How We Think

Automatic System

Reflective System

Controlled

Effortful

Deductive

Slow

Self-aware

Rule-following

  • Uncontrolled
  • Effortless
  • Associative
  • Fast
  • Unconscious
  • Skilled

Thaler and SunsteinNudge 2008

time for a new paradigm stpc
Time for a New Paradigm: STPC
  • Standardization(drugs, concentrations, equipment)
  • Technology(drug identification and delivery, automated information systems)
  • Pharmacy(satellite pharmacy, premixed solutions and prefilled syringes whenever possible)
  • Culture(recognition and reporting of drug errors to reduce recurrences)
slide27

Mass

1 mg/ml

Ratio

1 in 1000

Wheeler D et al Annals of Internal Medicine 2008

slide28

“Both systems scored significantly lower than standard equipment for overall performance of spinal and epidural procedures, although the performance of non-Luer devices was mostly rated ‘adequate’ or better”

“Both non-Luer connectors could cross-connect with one or more Luer connectors”

slide29

The Amsterdam Urinals

Choice Architecture

“It turns out that, if you give men a target, they can’t help but aim at it”

http://nudges.wordpress.com/the-amsterdam-urinals/

slide30

“… the rate of postoperative complications and death were reduced by more than one-third”

Haynes et al NEJM 360 491-9 2009

slide31

108 VA facilities: 182 409 sampled procedures 2006-8

  • Briefings debriefings and checklists
  • 74 vs 13: mortality RR
  • 0.82 (0.76-0.91) vs 0.93 (0.80-1.08)
  • (18% vs 7%)

Neily J et al JAMA 2010

slide32

De Vries et al NEJM 2010

Total complications 27.3 – 16.7 per 100 patients

In hospital mortality 1.5% - 0.8%

De Vries et al NEJM 2010

strategies for improving surgical quality checklists and beyond
Strategies for Improving Surgical Quality —Checklists and Beyond

“…checklists seem to have crossed the threshold from good idea to standard of care”

BirkmeyerNEJM 2010

some estimates of anaesthesia mortality
Some Estimates of Anaesthesia Mortality
  • Australia 1 in 56000
  • Zimbabwe 1 in 3000
  • Malawi 1 in 500
  • Togo 1 in 150

Gibbs and Rodoreda Anaesthesia and Intensive Care 2005

McKenzie South African Medical Journal 1996

Heywood et al Annals of Royal College of Surgeons of England 1989

Hansen et al Tropical Doctor 2000

Ouro-Bang'na et al Tropical Doctor 2005

togo avoidable anaesthetic mortality
Togo: Avoidable Anaesthetic Mortality
  • 74% of anaesthetic deaths due to respiratory causes:
    • Aspiration
    • Undetected oesophageal intubation
    • Postoperative hypoxia
    • Overdose
    • Difficult intubation
  • All cases could have been identified by pulse oximetry

Ouro-Bang’naMaman AF Tropical Doctor 2005 35: 220-22

Ouro-Bang'na et al Tropical Doctor 2005

(Slide modified from Walker I 2008)

slide36

77 700 ORs worldwide

and

31.5 million operations per year without oximetry

Funk et al Lancet 2010

slide37

77 700 ORs worldwide

and

31.5 million operations per year without oximetry

We have yet to identify a country that has minimal monitoring standards for anaesthesia in which pulse oximetry is not mandatory

Funk et al Lancet 2010

slide38

“HIGHLY RECOMMENDED: applicable throughout any elective procedure,

from patient evaluation until recovery (however, immediate life-saving measures always take

precedence in an emergency)”

global pulse oximetry project
Global Pulse Oximetry Project

Normal cost

around $750

education
Education
  • A huge challenge
  • Linked to local agreements and philosophy of sustainable change
  • One size will not fit all needs
  • Should address physiology and decision making
slide45

Training and practice

  • Appropriate equipment, facilities and support
  • Intelligent design
  • Process tools (including checklists and well designed simple algorithms)
  • Experience, experience, experience