crisisManagement-1 - Tony Chang MD Tuesday Conference...

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Unformatted text preview: 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. possible Other professions like ours: Other Aviation Spaceflight Spaceflight Nuclear power and chemical manufacturing Military Command – Fighter Pilots in combat Fire fighting Complex and Dynamic Complex Event driven and dynamic Complex and tightly coupled Uncertain Risky What makes Anesthesia different from other specialties? from Dynamism Time pressure Intensity Complexity Uncertainty Risk The stress of anesthesia The Anesthesiology, by its nature, involves crises involves The combination of complexity and The dynamism makes crises much more likely to occur and more difficult to deal with. to Up to our elbows… Up Anesthesia involves direct physical Anesthesia involvement in the tasks of patient care including: including: - performance of invasive procedures - administration of rapidly acting, administration potentially lethal medications potentially - operation of increasingly complex operation devices During crises, knowledge is not enough.. enough.. Management of the environment, the Management equipment and the patient care team equipment This involves aspects of cognitive and social This psychology, sociology and anthropology psychology, Old View Old Adequate Training + Qualified Trainee = Adequate Ability to handle Crisis Situations Ability New View New Each individual is affected by multiple Each factors…. factors…. – Individual strengths and vulnerabilities – Distractions, biases, errors – Environment, Equipment – Physiologic factors such as fatigue, emotional Physiologic stress, illness stress, Error: Old vs New Error: It happened all of a sudden… It Crisis perceived as sudden in onset and Crisis rapid in development rapid In retrospect one can usually identify an In evolution from underlying triggering events evolution triggering Gaba DM, Fish KJ, Howard SK: Crisis Management in Anesthesia 1994 Triggering events may initiate a problem. A problem is an problem problem 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. adverse Adverse Outcome… Adverse The events that trigger problems do not occur at random not They emerge from three sets of underlying They conditions: conditions: – Latent errors – Predisposing factors – Psychological precursors 1. Latent Errors: 1. …errors whose adverse consequences errors may lie dormant within the system for a long time, only becoming evident when they combine with other factors to breach the system’s defenses, most likely spawned by those whose activities are removed in space and time from direct control: designers, adminstrators, managers. managers. 2. Predisposing Factors: 2. The external environment constitutes The predisposing factors. In aviation this is weather. In anesthesia In these are the patient’s underlying diseases and the nature of the surgery and 3. Psychological Precursors 3. Can predispose the surgeon or anesthesia Can provider to commit unsafe acts that may trigger a problem trigger “Performance Shaping Factors” including Performance fatigue, boredom, illness, drugs, environment (noise, illumination) environment Eliminating the Latent Factors Eliminating Most of the latent factors affecting Most anesthesia are too complex to analyze and find a single cause find Most effective strategy is targeted at Most individual cases including 1) the patient 2) the surgeon and anesthesia provider 3) the equipment equipment Complex Dynamic Worlds Complex 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 Sociology of the OR Sociology Ambiguous Command Ambiguous Structure Structure OR “team” is actually OR several “crews” several – Surgery, Surgery, Anesthesiology, Nursing, Secretarial, Housekeeping Housekeeping Each Crew has its own Each command hierarchy and structure and “Expertise” in Anesthesia (or who would Expertise” I choose to do MY anesthesia) MY Intelligence + Motivation + anesthesia Intelligence training = Expertise in anesthesia (?) training CME’s, Refresher Courses, M & M CME’s, conferences – maintains “expertise” (?) conferences Is every “expert” then a good crisis Is manager? manager? Human Performance Human The concept of “performance” is difficult to The define define – No “Gold Standard” – Difficult to measure Data tends to be subjective Critical Incidents in the OR Critical Elements of Core Mental Process Elements Observation Verification Problem Recognition Prediction of future states Decision-making Action implementation Reevaluation Start again with observation Problem Recognition Problem Matching sets of environmental cues to Matching patterns that are known to represent specific types of problems types “Heuristics” – approximation strategies to Heuristics” handle ambiguous situations handle – Categorize into several “generic” problems, Categorize each with a differential each – Frequency Gambling Tasks Tasks Primary tasks – Completion is dependent on Task Load Secondary tasks – Completion is dependent on the priority of the Completion Primary Task Primary Vigilance and Workload Vigilance Multi-Tasking in the OR Multi-Tasking Prospective Memory Prospective One’s ability to remember in the future to One’s perform an action (i.e. restart the ventilator, administer medications, eye check) administer Interruptions and “break-in-tasks” Interruptions frequently delay or prevent frequently During a 3 hour period in the ED there During were more than 30 interruptions and more than 20 breaks-in-task* than Chisholm CD, Collison EK, Nelson DR, Cordell WH: Emergency department workplace interruptions:Are emergency physicians “interrupt-drive” and “multitasking”? Acad Emerg Med 7:1239-1243, 2000 Fixation Errors Fixation The persistent failure to revise a diagnosis The or plan in the face of readily available evidence that suggest a revision is necessary necessary 3 types of Fixation Errors types “This and only this!” “Everything but this!” “Everything is OK!” “Perhaps the most insidious hazard of Perhaps 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 flawlessly Cooper JB, Newbower RS, Kitz RJ: An analysis of major errors and equipment failures in anesthesia management: Considerations for prevention and detection. Anesthesiology 60:34-42, 1984 Hazardous Attitudes Hazardous Production Pressure Production 49% witnessed an event where patient 49% safety was comprised due to pressure safety 32% experienced strong pressure from 32% surgeons to proceed with a case they wished to cancel wished 20% responded, “sometimes I have altered 20% my practices to hasten the start of a case” my Other complex worlds like ours Other Military aviation – the desire to optimize human Military performance stems from the desire of the pilot to stay alive performance 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 Commerical aviation, CRM training (based on the workshop, Management on the Flightdeck, sponsored by NASA 1979) Management Anesthesia and Aviation Anesthesia Vigilance… Vigilance… Both Aviation and Both Anesthesia are describe as…”99% boredom and 1% Sheer Terror….” Sheer 99% Boredom…. 99% 1% Sheer Terror 1% Interesting Parallels Interesting Preop Evaluation Machine/Equipment Machine/Equipment check check Induction Deepening Anesthesia Intraop Lightening Anesthesia Emergence Preflight Aircraft and preflight Aircraft checklist checklist Take Off Gaining Altitude Cruise Altitude Descent Landing Dials, Knobs and Alarms Dials, “Cruising, Stormy and Crashing” Similar Environments… Similar High Stress Potential Work hours and Performance Equipment Dependent Production Pressures Communication and Team Approach Multiple Tasking Accident Evolution The flight is only as good as the landing The Vigilance… Vigilance… …Ability of observers to remain alert to Ability stimuli for prolonged periods of time… stimuli Warm J, Presentation at the panel on Warm vigilance, 1992 ASA annual meeting vigilance, Situation Awareness Situation First identified as important to fighter First combat pilots and later to Commercial Aviation Aviation Integral for expert performance involving – Dynamic complexity – High information load/Variable Workload – High Risk Time Compression Features of Situation Awareness Features Multi-observatioin Verification Problem Recognition/Cues Prediction of Future States Precompiled Responses/Abstract Reasoning Action/Implementation Reevaluation Fixation Errors Situational Awareness Situational SITUATIONAL AWARENESS SITUATIONAL Situational Awareness refers to the degree of accuracy by which one's perception of his current environment mirrors reality. environment PERCEPTION VERSUS REALITY View of Situation Incoming information Expectations & Biases Incoming Information versus Expectations FACTORS THAT REDUCE FACTORS SITUATIONAL AWARENESS SITUATIONAL Insufficient Communication Fatigue / Stress Task Overload Task Underload Group Mindset "Press on Regardless" Philosophy Degraded Operating Conditions Naval Aviation Schools Command, Pensacola FL Crew Resource Management Crew Workshop, “Resource Management on the Workshop, Flight Deck” sponsored by NASA in 1979 Flight Conference by NASA to research causes of Conference air transport accidents. air Research identified human error aspects of Research majority of air crashes as failures of communication, decision making and leadership leadership The label, “Cockpit Resource Management The (CRM)” was applied to the process of training crews to reduce pilot error by making better use of the human resources on the flightdeck on Crisis Resource Management Crisis Originally Crew Resource Management Problems arise not from poor skills but from Problems inability to utilize resources effectively inability Team Team …a distinguishable set of two or more distinguishable 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 limited Principles of CRM Principles Delegation/Assignment of Delegation/Assignment Tasks/Responsibilities Tasks/Responsibilities Priority Assessment Monitoring/Cross checking Communication Leadership Problem Assessment/Avoid Preoccupation Simulators Simulators Simulation Training Simulation Allows practice in situations that rarely occur Allows in real life in Safe environment for practicing crises Safe situations situations Mandatory training in Netherlands, Belgium, Mandatory Sweden and Germany Sweden Allows safe environment for research 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 Anesthesia Patient Safety Foundation Anesthesia In 1983, the Royal Society of Medicine of England and the In Harvard Medical School jointly sponsored a symposium on anesthesia contributory morbidity and mortality One year later, at the 1984 meeting of the American One Society of Anesthesiologists, Dr. Ellison C.Pierce, the Society's President, inaugurated the Anesthesia Patient Safety Foundation (APSF) Safety Aviation Safety Reporting System Aviation The Aviation Safety Reporting System (ASRS) is funded by the 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 punishment The ASRS entails the collection, analysis, and response to aviation The 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. Safety Reporting Systems Safety Making Things Safer Making Since the early 1980s, the Anesthesia Patient Safety Foundation Since (APSF) has been instrumental in reducing the number of anesthesia(APSF) related deaths from 1 in 10,000 to about 1 in 200,000. Technological related advances -- such as pulse oximeters, capnometers, and oxygen regulators have been key factors. Also, simulators are now used in anesthesia for practice and training. anesthesia Online CME sponsored by Massachusetts Medical Society, file:///C:/Documents%20and %20Settings/Christopher/Desktop/New%20Folder/New %20Folder/Online%20CME%20%20A%20Success %20Story%20in%20Safety.htm ...
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