Principles of Anesthesiology Nursing V Crisis Management in Anesthesia

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Principles of Anesthesiology Nursing VCrisis
Management in Anesthesia Jeffrey Groom, PhD,
CRNADirector and Clinical Associate
ProfessorAnesthesiology Nursing Program
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High Risk Environments
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Medical Errors
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To err is human
The human cost of medical errors is high. Based
on the findings of one major study, medical
errors kill some 44,000 people in U.S. hospitals
each year. Another study puts the number much
higher, at 98,000. Even using the lower estimate,
more people die from medical mistakes each year
than from highway accidents, breast cancer, or
AIDS.
To Err Is Human asserts that the problem is not
bad people in health care--it is that good people
are working in bad systems that need to be made
safer.
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Medical Errors

• Wrong patient
• Wrong procedure
• Wrong limb
• Wrong drug
• Wrong dose

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Adverse Events

• Analysis
• Prevention
• Management

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1,834 Aircraft Accident Causes by Category (percent) 1,834 Aircraft Accident Causes by Category (percent) 1,834 Aircraft Accident Causes by Category (percent) 1,834 Aircraft Accident Causes by Category (percent) 1,834 Aircraft Accident Causes by Category (percent) 1,834 Aircraft Accident Causes by Category (percent) 1,834 Aircraft Accident Causes by Category (percent)
Cause 50s 60s 70s 80s 90s ALL
 Pilot Error 27 24 18 21 20 22
 Pilot Error  (weather related) 6 12 9 11 11 10
 Pilot Error (mechanical related) 4 3 3 2 3 3
 Total Pilot Error 37 39 30 34 34 35
 Other Human Error 2 5 5 4 6 4
 Weather 10 7 9 11 11 10
 Mechanical Failure 13 14 12 15 18 14
 Sabotage 3 3 7 10 6 6
 Other Cause 1 2 1 1 1 1
 Undetermined or missing 34 30 36 25 24 30
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Why study Human Performance in Anesthesia

• Enhance patient safety
• Enhance provider safety
• Improve procedures and practices
• Enhance training
• More rational understanding of work
• Better understanding of reasonable
• More effective work environment

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Accident Causation

• Complexity
• Tight Coupling
• Latent Errors

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Complex Anesthesia Environment
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Accident Causation
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VIGILANCE
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Human Performance Factors in Anesthesia Care

• Complex systems
• Environment
• Distraction
• Production Pressure
• Fatigue
• Boredom
• Illness Medication
• Attitude
• Age

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After Action Review
EAL 401 Crash video review
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07-03-88 _at_ 1047 1048 1049 1050 1051
1052 1053 1054
ALERT gt TARGET gt FIRE
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After Action Analysis
TECHNOLOGY
OPERATIONS
HUMAN FACTORS
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CIC Simulation Training
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Decision Making Under Stress
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Medical EmergencyDecision Making Under Stress
Technology Operations Human Factors
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Performance Under Stress

• INPUT
• Information Communication Tunnel Vision
• PROCESSING
• Decision Making Accuracy Prioritization
• OUTPUT
• Actions Omissions - Skills

Stress Improves Performance
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Crisis Management in Anesthesiology
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Crew Resource Management
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Decision Making in Anesthesia
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Crew Resource Management

• Prioritize
• Communicate
• Delegate
• Coordinate
• Resources
• Monitor
• Reassess

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CRM Key Principles
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Anesthetists Non-Technical Skills
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Anesthetists Non-Technical Skills
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Crew Resource Management

• Prioritize
• Communicate
• Delegate
• Coordinate
• Resources
• Monitor
• Reassess