Human errors

Educational Objectives

The goal of this program is to encourage practices that improve the culture of safety in operating rooms. After hearing and assimilating this program, the clinician will be better able to:

1. Anticipate and prepare for times and situations in which errors are most likely to occur.

2. Use evidence-based strategies for reducing medical errors.

Summary

Errors in anesthesiology: time pressures may require decisions without complete information; clinical consequences of errors may be devastating

High-risk times and situations (lessons from nuclear power industry): 30 min after meal; environment with many distractions; first day back from weekend or vacation; use of vague or incorrect written procedures; overconfidence; heavy workload; imprecise oral communication; work stress

“Swiss cheese” model of errors: active failures — unintentional or intentional; latent risk factors — “resident pathogens” (system-based errors); if both align, problem occurs

Latent risk factors: operating room — environmental; related to equipment design or maintenance; related to planning and organization; use of clear protocols can increase system safety; having appropriate staff for volume of procedures planned also increases safety; cultural factors that increase safety — teamwork; good communication; adherence to policies and protocols; compatibility of goals among all players (eg, surgeon and institution should agree on goals for patient volume); situational awareness (team recognizes and works toward common goals)

Medication errors: 50% related to administration

Evidence-based strategies for reducing errors: formal organization of drug drawers and workspaces (designated areas for specific medicines); standardization of labels; labeling of syringes (unless used immediately); mindful examination of every label before use

Components of safe culture: all participants know plan and take ownership of their roles in it; team members feel comfortable voicing concerns; willingness to confront rule violations; respect among all team members (turnover of nursing staff closely reflects safety of hospital culture); maintenance of safety edge (judicious expansion of limits; eg, scheduling 70 cases in operating room staffed for 50 cases may be technically unsafe, but risks may be manageable; scheduling 110 cases unequivocally dangerous)

Practices that should not be normalized: removing monitors at end of general anesthesia, before patient has awakened; transferring care of patient at vital times during operation; failure to recognize isolation procedures and protocols; failure to wash hands; inadequate monitoring of effects of neuromuscular blocking agents; failure to examine laboratory results before surgery; excessive noise in operating room during critical situations; placement of nonsterile dressings on catheter dressings; failure to place standard monitors before placing nerve block

Fixation error: fixation on one error distracts from others

Conclusions: culture of safety requires ongoing vigilance to anticipate changes, good teamwork, and situational awareness; specific responsibilities should be assigned to specific people; clinicians should be able to monitor situation and be flexible enough to change plans when necessary; focus on task but maintain awareness of environment and interaction of other staff; look ahead and consider contingencies; create visual and auditory reminders

Readings

Brandom BW et al: What happens when things go wrong? Pediatr Anesth 2011 Jul;21(7):730-6; Clever SL et al: Does doctor-patient communication affect patient satisfaction with hospital care? Results of an analysis with a novel instrumental variable. Health Serv Res 2008 May 3 [Epub ahead of print]; Gallagher TH et al: Disclosing harmful medical errors to patients. N Engl J Med 2007 Jun 28;356(26):2713-9; Golemboski K: Improving patient safety: lessons from other disciplines. Clin Lab Sci 2011 Spring;24(2):114-9; Heard GC et al: Barriers to adverse event and error reporting in anesthesia. Anesth Analg 2012 Mar;114(3):604-14; Levinson W: Patient-centred communication: a sophisticated procedure. BMJ Qual Saf 2011 Oct;20(10):823-5; Loren DJ et al: Risk managers, physicians, and disclosure of harmful medical errors. Jt Comm Qual Patient Saf 2010 Mar;36(3):101-8; Metzner J et al: Closed claims analysis. Best Pract Res Clin Anaesthesiol 2011 Jun;25(2):263-76; Prielipp RC et al: The normalization of deviance: do we (un)knowingly accept doing the wrong thing? Anesth Analg 2010 May 1;110(5):1499-502; Reason J: James Reason: patient safety, human error, and Swiss cheese. Interview by Karolina Peltomaa and Duncan Neuhauser. Qual Manag Health Care 2012 Jan-Mar;21(1):59-63; Vincent C et al: Why do people sue doctors? A study of patients and relatives taking legal action. Lancet 1994 Jun 25;343(8913):1609-13

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Enneking spoke at 24th Annual Winter Anesthesia Conference, held March 4-8, 2012, in Snowmass Village, CO, and sponsored by the University of Florida College of Medicine, Department of Anesthesiology. For CME information from the University of Florida College of Medicine, visit cme.ufl.edu. You may also check our website, audio-digest.org, under Upcoming Meetings. The Audio-Digest Foundation thanks the speaker and the sponsor for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

AN541102

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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