The Human Factor – Finessing the White Bears Alan Merry Professor and HOD Anaesthesiology
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The Human Factor – Finessing the White Bears
Alan MerryProfessor and HOD Anaesthesiology
University of Auckland
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DisclosureAlan Merry has financial interests in
Safer Sleep LLCIs on the Boards of
Safer Sleep LLCNZ Health Quality and Safety Commission
LifeboxANZCA (ie as a Councillor)
and has received support for research from ANZCAWHO
HRC NZAFT Pharmaceuticals
Roche Baxterand others
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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
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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
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Runciman Merry Walton 2006
Adverse Event Rates from Medical Record Reviews
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NEJM Nov 2010
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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
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Reason BMJ 2000
Latent factors and
Swiss cheese
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Errors
• Experts make errors• Not carelessness• Deterrence useless• Medical practice is challenging
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Errors - Definition
When you are trying to do the right thing but you actually do the wrong thing
Focus on process not outcome
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Violations
• Element of choice• May be carelessness• Deterrence may be effective
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Violations
• Element of choice• May be carelessness• Deterrence may be effective
• Not always reprehensible• Systems double-bind
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Classification of Error
• Action failure• Skill-based (slips and lapses)• Technical (dural tap)
• Decision or planning failure• Rule-based • Knowledge-based
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Classification of Error
• Action failure• Skill-based (slips and lapses)• Technical (dural tap)
• Decision or planning failure• Rule-based • Knowledge-based Errors of reasoning
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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 1972http://en.wikipedia.org/
wiki/File:Edward_lorenz.jpg
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Problems
• Simple ( baking a cake) • Complicated (going to the moon)• Complex (raising a child)
Zimmerman and GloubermanCited in Gawande The Checklist Manifesto 2010
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How We Think
Automatic System• Uncontrolled• Effortless• Associative• Fast• Unconscious• Skilled
Reflective System• Controlled• Effortful• Deductive • Slow• Self-aware• Rule-following
Thaler and Sunstein Nudge 2008
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Wegner DM et al Psychological Science 1998
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Gibbs N Anaesth Intensive Care 2005
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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)
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Mass1 mg/ml
Ratio1 in 1000
Wheeler D et al Annals of Internal
Medicine 2008
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“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”
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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/
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Haynes et al NEJM 360 491-9 2009
“… the rate of postoperative complications and death were reduced by more than one-third”
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• 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
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De Vries et al NEJM 2010
De Vries et al NEJM 2010
Total complications 27.3 – 16.7 per 100 patientsIn hospital mortality 1.5% - 0.8%
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Strategies for Improving Surgical Quality —
Checklists and Beyond
Birkmeyer NEJM 2010
“…checklists seem to have crossed the threshold from good idea to standard of
care”
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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 1996Heywood et al Annals of Royal College of Surgeons of
England 1989Hansen et al Tropical Doctor 2000
Ouro-Bang'na et al Tropical Doctor 2005
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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’na Maman AF Tropical Doctor 2005 35: 220-22
Ouro-Bang'na et al Tropical Doctor 2005(Slide modified from Walker I 2008)
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77 700 ORs worldwide
and 31.5 million
operations per year without
oximetry
Funk et al Lancet 2010
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77 700 ORs worldwide
and 31.5 million
operations per year without
oximetry
Funk et al Lancet 2010
We have yet to identify a country that has minimal monitoring standards for anaesthesia in which pulse
oximetry is not mandatory
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“HIGHLY RECOMMENDED: applicable throughout any elective procedure,from patient evaluation until recovery (however, immediate life-saving measures always takeprecedence in an emergency)”
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Global Pulse Oximetry Project
Normal cost around $750
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Global Pulse Oximetry Project
$250 delivered$25
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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
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Educational CDROM – 6 Languages
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• Training and practice• Appropriate equipment,
facilities and support• Intelligent design• Process tools (including
checklists and well designed simple algorithms)
• Experience, experience, experience
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www.lifebox.org