The Human Factor – Finessing the White Bears Alan Merry Professor and HOD Anaesthesiology

1. The Human Factor – Finessing the White Bears Alan Merry Professor and HOD Anaesthesiology University of Auckland

2. 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

4. 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

6. 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

7. Adverse Event Rates from Medical Record Reviews Runciman Merry Walton 2006

8. NEJM Nov 2010

9. 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

10. Latent factors and Swiss cheese Reason BMJ 2000

11. Errors • Experts make errors • Not carelessness • Deterrence useless • Medical practice is challenging

12. Errors - Definition • When you are trying to do the right thing but you actually do the wrong thing • Focus on process not outcome

14. Violations • Element of choice • May be carelessness • Deterrence may be effective

15. Violations • Element of choice • May be carelessness • Deterrence may be effective • Not always reprehensible • Systems double-bind

16. Classification of Error • Action failure • Skill-based (slips and lapses) • Technical (dural tap) • Decision or planning failure • Rule-based • Knowledge-based

17. Classification of Error • Action failure • Skill-based (slips and lapses) • Technical (dural tap) • Decision or planning failure • Rule-based • Knowledge-based Errors of reasoning

18. 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

19. Problems • Simple ( baking a cake) • Complicated (going to the moon) • Complex (raising a child) Zimmerman and Glouberman Cited in GawandeThe Checklist Manifesto 2010

20. How We Think

21. 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

22. Wegner DM et al Psychological Science 1998

23. Gibbs N Anaesth Intensive Care 2005

26. 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)

27. Mass 1 mg/ml Ratio 1 in 1000 Wheeler D et al Annals of Internal Medicine 2008

28. “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”

29. 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/

30. “… the rate of postoperative complications and death were reduced by more than one-third” Haynes et al NEJM 360 491-9 2009

31. 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

32. 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

33. Strategies for Improving Surgical Quality —Checklists and Beyond “…checklists seem to have crossed the threshold from good idea to standard of care” BirkmeyerNEJM 2010

34. 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

35. 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)

36. 77 700 ORs worldwide and 31.5 million operations per year without oximetry Funk et al Lancet 2010

37. 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

38. “HIGHLY RECOMMENDED: applicable throughout any elective procedure, from patient evaluation until recovery (however, immediate life-saving measures always take precedence in an emergency)”

40. Global Pulse Oximetry Project Normal cost around $750

41. Global Pulse Oximetry Project $250 delivered $25

42. 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

43. Educational CDROM – 6 Languages

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

46. www.lifebox.org