Crisis: (definition)

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Tony Chang, MD Tuesday Conference September 6,
2005
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Crisis

• A time of great danger or trouble whose outcome
  decides whether possible bad consequences will
  follow.

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Other professions like ours

• Aviation
• Spaceflight
• Nuclear power and chemical manufacturing
• Military Command Fighter Pilots in combat
• Fire fighting

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Complex and Dynamic

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

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What makes Anesthesia different from other
specialties?

• Dynamism
• Time pressure
• Intensity
• Complexity
• Uncertainty
• Risk

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The stress of anesthesia
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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.

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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

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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

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Old View

• Adequate Training Qualified Trainee Ability
  to handle Crisis Situations

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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

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Error Old vs New
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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

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Gaba DM, Fish KJ, Howard SK Crisis Management in
Anesthesia 1994
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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.
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Adverse Outcome
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The events that trigger problems do not occur at
random

• They emerge from three sets of underlying
  conditions
• Latent errors
• Predisposing factors
• Psychological precursors

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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.

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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

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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)

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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

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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

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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

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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?

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Human Performance

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

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Critical Incidents in the OR
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Elements of Core Mental Process

• Observation
• Verification
• Problem Recognition
• Prediction of future states
• Decision-making
• Action implementation
• Reevaluation
• Start again with observation

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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

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Tasks

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

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Vigilance and Workload
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Multi-Tasking in the OR
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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
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Fixation Errors

• The persistent failure to revise a diagnosis or
  plan in the face of readily available evidence
  that suggest a revision is necessary

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3 types of Fixation Errors

• This and only this!
• Everything but this!
• Everything is OK!

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• 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
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Hazardous Attitudes
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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

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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)

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Anesthesia and Aviation
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Vigilance

• Both Aviation and Anesthesia are describe as99
  boredom and 1 Sheer Terror.

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99 Boredom.
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1 Sheer Terror
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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

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Dials, Knobs and Alarms
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Cruising, Stormy and Crashing
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Similar Environments

• High Stress Potential
• Work hours and Performance
• Equipment Dependent
• Production Pressures
• Communication and Team Approach
• Multiple Tasking
• Accident Evolution

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The flight is only as good as the landing
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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

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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

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Features of Situation Awareness

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

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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
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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

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• 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

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Crisis Resource Management

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

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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

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Principles of CRM

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

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Simulators
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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

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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
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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)

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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.

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Safety Reporting Systems
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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
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