Crisis: (definition) - PowerPoint PPT Presentation

Loading...

PPT – Crisis: (definition) PowerPoint presentation | free to view - id: 3b38be-NmJhY



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Crisis: (definition)

Description:

Tony Chang, MD Tuesday Conference September 6, 2005 Crisis: A time of great danger or trouble whose outcome decides whether possible bad consequences will follow. – PowerPoint PPT presentation

Number of Views:85
Avg rating:3.0/5.0
Slides: 76
Provided by: anesthesi8
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Crisis: (definition)


1
Tony Chang, MD Tuesday Conference September 6,
2005
2
Crisis
  • A time of great danger or trouble whose outcome
    decides whether possible bad consequences will
    follow.

3
(No Transcript)
4
Other professions like ours
  • Aviation
  • Spaceflight
  • Nuclear power and chemical manufacturing
  • Military Command Fighter Pilots in combat
  • Fire fighting

5
Complex and Dynamic
  • Event driven and dynamic
  • Complex and tightly coupled
  • Uncertain
  • Risky

6
What makes Anesthesia different from other
specialties?
  • Dynamism
  • Time pressure
  • Intensity
  • Complexity
  • Uncertainty
  • Risk

7
The stress of anesthesia
8
Anesthesiology, by its nature, involves crises
  • The combination of complexity and dynamism makes
    crises much more likely to occur and more
    difficult to deal with.

9
Up to our elbows
  • Anesthesia involves direct physical involvement
    in the tasks of patient care including
  • - performance of invasive procedures
  • - administration of rapidly acting,
    potentially lethal medications
  • - operation of increasingly complex
    devices

10
During crises, knowledge is not enough..
  • Management of the environment, the equipment and
    the patient care team
  • This involves aspects of cognitive and social
    psychology, sociology and anthropology

11
Old View
  • Adequate Training Qualified Trainee Ability
    to handle Crisis Situations

12
New View
  • Each individual is affected by multiple factors.
  • Individual strengths and vulnerabilities
  • Distractions, biases, errors
  • Environment, Equipment
  • Physiologic factors such as fatigue, emotional
    stress, illness

13
Error Old vs New
14
It happened all of a sudden
  • Crisis perceived as sudden in onset and rapid in
    development
  • In retrospect one can usually identify an
    evolution from underlying triggering events

15
Gaba DM, Fish KJ, Howard SK Crisis Management in
Anesthesia 1994
16
Triggering events may initiate a problem. A
problem is an abnormal situation that requires
attention but is unlikely by itself to cause
harm. Problems can evolve and if not detected or
corrected can lead to adverse outcomes.
17
Adverse Outcome
18
The events that trigger problems do not occur at
random
  • They emerge from three sets of underlying
    conditions
  • Latent errors
  • Predisposing factors
  • Psychological precursors

19
1. Latent Errors
  • errors whose adverse consequences may lie
    dormant within the system for a long time, only
    becoming evident when they combine with other
    factors to breach the systems defenses, most
    likely spawned by those whose activities are
    removed in space and time from direct control
    designers, adminstrators, managers.

20
2. Predisposing Factors
  • The external environment constitutes predisposing
    factors.
  • In aviation this is weather. In anesthesia these
    are the patients underlying diseases and the
    nature of the surgery

21
3. Psychological Precursors
  • Can predispose the surgeon or anesthesia provider
    to commit unsafe acts that may trigger a problem
  • Performance Shaping Factors including fatigue,
    boredom, illness, drugs, environment (noise,
    illumination)

22
(No Transcript)
23
Eliminating the Latent Factors
  • Most of the latent factors affecting anesthesia
    are too complex to analyze and find a single
    cause
  • Most effective strategy is targeted at individual
    cases including 1) the patient 2) the surgeon and
    anesthesia provider 3) the equipment

24
Complex Dynamic Worlds
  • Ill-structured problems
  • Uncertain dynamic environment
  • Time Stress
  • Shifting, ill-defined or competing goals
  • Action/feedback loops
  • High stakes
  • Multiple Players
  • Organizational goals and norms
  • Orasanu J, Conolly T The reinvention of decision
    making, 1993, pp 3-20

25
Sociology of the OR
  • Ambiguous Command Structure
  • OR team is actually several crews
  • Surgery, Anesthesiology, Nursing, Secretarial,
    Housekeeping
  • Each Crew has its own command hierarchy and
    structure

26
Expertise in Anesthesia (or who would I choose
to do MY anesthesia)
  • Intelligence Motivation anesthesia training
    Expertise in anesthesia (?)
  • CMEs, Refresher Courses, M M conferences
    maintains expertise (?)
  • Is every expert then a good crisis manager?

27
Human Performance
  • The concept of performance is difficult to
    define
  • No Gold Standard
  • Difficult to measure
  • Data tends to be subjective

28
(No Transcript)
29
Critical Incidents in the OR
30
(No Transcript)
31
Elements of Core Mental Process
  • Observation
  • Verification
  • Problem Recognition
  • Prediction of future states
  • Decision-making
  • Action implementation
  • Reevaluation
  • Start again with observation

32
Problem Recognition
  • Matching sets of environmental cues to patterns
    that are known to represent specific types of
    problems
  • Heuristics approximation strategies to handle
    ambiguous situations
  • Categorize into several generic problems, each
    with a differential
  • Frequency Gambling

33
Tasks
  • Primary tasks
  • Completion is dependent on Task Load
  • Secondary tasks
  • Completion is dependent on the priority of the
    Primary Task

34
Vigilance and Workload
35
Multi-Tasking in the OR
36
Prospective Memory
  • Ones ability to remember in the future to
    perform an action (i.e. restart the ventilator,
    administer medications, eye check)
  • Interruptions and break-in-tasks frequently
    delay or prevent
  • During a 3 hour period in the ED there were more
    than 30 interruptions and more than 20
    breaks-in-task

Chisholm CD, Collison EK, Nelson DR, Cordell WH
Emergency department workplace interruptionsAre
emergency physicians interrupt-drive and
multitasking? Acad Emerg Med 71239-1243, 2000
37
Fixation Errors
  • The persistent failure to revise a diagnosis or
    plan in the face of readily available evidence
    that suggest a revision is necessary

38
3 types of Fixation Errors
  • This and only this!
  • Everything but this!
  • Everything is OK!

39
  • Perhaps the most insidious hazard of anesthesia
    is its relative safety. The individual
    anesthetist is rarely responsible for serious
    complications. It is our impressions that most
    seemingly minor errors are not taken seriously
    and risk management depends almost solely on the
    anesthetists ability to react instinctively and
    flawlessly

Cooper JB, Newbower RS, Kitz RJ An analysis of
major errors and equipment failures in anesthesia
management Considerations for prevention and
detection. Anesthesiology 6034-42, 1984
40
Hazardous Attitudes
41
Production Pressure
  • 49 witnessed an event where patient safety was
    comprised due to pressure
  • 32 experienced strong pressure from surgeons to
    proceed with a case they wished to cancel
  • 20 responded, sometimes I have altered my
    practices to hasten the start of a case

42
Other complex worlds like ours
  • Military aviation the desire to optimize human
    performance stems from the desire of the pilot to
    stay alive
  • Nuclear Power Three Mile Island and Chernobyl
  • Chemical Union Carbide plant, Bhopal India
  • Spaceflight Space Shuttles Challenger and
    Columbia
  • Commerical aviation learning from the lessons
    of military aviation, CRM training (based on the
    workshop, Management on the Flightdeck, sponsored
    by NASA 1979)

43
(No Transcript)
44
(No Transcript)
45
Anesthesia and Aviation
46
(No Transcript)
47
Vigilance
  • Both Aviation and Anesthesia are describe as99
    boredom and 1 Sheer Terror.

48
99 Boredom.
49
1 Sheer Terror
50
Interesting Parallels
  • Preflight
  • Aircraft and preflight checklist
  • Take Off
  • Gaining Altitude
  • Cruise Altitude
  • Descent
  • Landing
  • Preop Evaluation
  • Machine/Equipment check
  • Induction
  • Deepening Anesthesia
  • Intraop
  • Lightening Anesthesia
  • Emergence

51
Dials, Knobs and Alarms
52
Cruising, Stormy and Crashing
53
Similar Environments
  • High Stress Potential
  • Work hours and Performance
  • Equipment Dependent
  • Production Pressures
  • Communication and Team Approach
  • Multiple Tasking
  • Accident Evolution

54
The flight is only as good as the landing
55
Vigilance
  • Ability of observers to remain alert to stimuli
    for prolonged periods of time
  • Warm J, Presentation at the panel on vigilance,
    1992 ASA annual meeting

56
Situation Awareness
  • First identified as important to fighter combat
    pilots and later to Commercial Aviation
  • Integral for expert performance involving
  • Dynamic complexity
  • High information load/Variable Workload
  • High Risk
  • Time Compression

57
Features of Situation Awareness
  • Multi-observatioin
  • Verification
  • Problem Recognition/Cues
  • Prediction of Future States
  • Precompiled Responses/Abstract Reasoning
  • Action/Implementation
  • Reevaluation
  • Fixation Errors

58
Situational Awareness
  • SITUATIONAL AWARENESS Situational Awareness
    refers to the degree of accuracy by which one's
    perception of his current environment mirrors
    reality.
  • PERCEPTION VERSUS REALITY View of Situation
    Incoming information Expectations Biases
    Incoming Information versus Expectations
  • FACTORS THAT REDUCE SITUATIONAL AWARENESS
    Insufficient Communication Fatigue / Stress
    Task Overload Task Underload Group Mindset
    "Press on Regardless" Philosophy Degraded
    Operating Conditions

Naval Aviation Schools Command, Pensacola FL
http//wwwnt.cnet.navy.mil/crm/crm/stand_mat/seven
_skills/SA.asp
59
Crew Resource Management
  • Workshop, Resource Management on the Flight
    Deck sponsored by NASA in 1979
  • Conference by NASA to research causes of air
    transport accidents.
  • Research identified human error aspects of
    majority of air crashes as failures of
    communication, decision making and leadership

60
  • The label, Cockpit Resource Management (CRM)
    was applied to the process of training crews to
    reduce pilot error by making better use of the
    human resources on the flightdeck

61
Crisis Resource Management
  • Originally Crew Resource Management
  • Problems arise not from poor skills but from
    inability to utilize resources effectively

62
Team
  • a distinguishable set of two or more people who
    interact dynamically, independently, and
    adaptively toward a common and valued
    goal/objective/mission, who have each been
    assigned specific roles or functions to perform
    and who have a limited life-span of membership

63
Principles of CRM
  • Delegation/Assignment of Tasks/Responsibilities
  • Priority Assessment
  • Monitoring/Cross checking
  • Communication
  • Leadership
  • Problem Assessment/Avoid Preoccupation

64
Simulators
65
Simulation Training
  • Allows practice in situations that rarely occur
    in real life
  • Safe environment for practicing crises situations
  • Mandatory training in Netherlands, Belgium,
    Sweden and Germany
  • Allows safe environment for research

66
(No Transcript)
67
(No Transcript)
68
(No Transcript)
69
History and Anesthesia Safety
"There was a reason for not publishing a paper
entitled, Etherization, in which I describe the
process as we then knew it. I recall that the
reason for not publishing it was because it
described in detail the case which I lost in the
OR because I was paying attention to some Tom
foolery which you, who had come in from the
theatre, were entertaining us with while the poor
devil was inhaling vomitus. Classmate writing
to Harvey Cushing, February 9, 1920
70
Anesthesia Patient Safety Foundation
  • In 1983, the Royal Society of Medicine of England
    and the Harvard Medical School jointly sponsored
    a symposium on anesthesia contributory morbidity
    and mortality
  • One year later, at the 1984 meeting of the
    American Society of Anesthesiologists, Dr.
    Ellison C.Pierce, the Society's President,
    inaugurated the Anesthesia Patient Safety
    Foundation (APSF)

71
Aviation Safety Reporting System
  • The Aviation Safety Reporting System (ASRS) is
    funded by the Federal Aviation Administration
    (FAA) but administered by National Aeronautical
    and Space Agency (NASA). The point of this
    arrangement is to focus on the prevention of
    accidents, not on the punishment of individuals
  • The ASRS entails the collection, analysis, and
    response to aviation safety incident reports,
    that are submitted voluntarily. This includes
    reports on near misses, where an error or safety
    violation has occurred but did not result in an
    accident. In fact, reporting and analysis of near
    misses is invaluable for safety improvement
    because it allows people to focus on the
    interactions between system elements, identify
    design flaws, and fix the problem before anyone
    is harmed by a system failure.

72
Safety Reporting Systems
73
Making Things Safer
  • Since the early 1980s, the Anesthesia Patient
    Safety Foundation (APSF) has been instrumental in
    reducing the number of anesthesia-related deaths
    from 1 in 10,000 to about 1 in 200,000.
    Technological advances -- such as pulse
    oximeters, capnometers, and oxygen regulators
    have been key factors. Also, simulators are now
    used in anesthesia for practice and training.

Online CME sponsored by Massachusetts Medical
Society, file///C/Documents20and20Settings/Chr
istopher/Desktop/New20Folder/New20Folder/Online
20CME2020A20Success20Story20in20Safety.htm
74
(No Transcript)
75
(No Transcript)
About PowerShow.com