Transcript crisisManagement

Crisis:
A time of great danger or trouble
whose outcome decides whether
possible bad consequences will follow.
Other professions like ours:
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Aviation
Spaceflight
Nuclear power and chemical manufacturing
Military Command – Fighter Pilots in combat
Fire fighting
Complex and Dynamic
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Event driven and dynamic
Complex and tightly coupled
Uncertain
Risky
What makes Anesthesia different
from other specialties?
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Dynamism
Time pressure
Intensity
Complexity
Uncertainty
Risk
The stress of anesthesia
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.
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
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
Old View
 Adequate Training + Qualified Trainee =
Ability to handle Crisis Situations
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
Error: Old vs New
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
Gaba DM, Fish KJ, Howard SK: Crisis Management in
Anesthesia 1994
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.
Adverse Outcome…
The events that trigger problems do
not occur at random
 They emerge from three sets of underlying
conditions:
– Latent errors
– Predisposing factors
– Psychological precursors
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 system’s defenses, most likely
spawned by those whose activities are
removed in space and time from direct
control: designers, adminstrators,
managers.
2. Predisposing Factors:
 The external environment constitutes
predisposing factors.
 In aviation this is weather. In anesthesia
these are the patient’s underlying diseases
and the nature of the surgery
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)
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
Complex Dynamic Worlds
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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
 Ambiguous Command
Structure
 OR “team” is actually
several “crews”
– Surgery,
Anesthesiology,
Nursing, Secretarial,
Housekeeping
 Each Crew has its own
command hierarchy
and structure
“Expertise” in Anesthesia (or who would
I choose to do MY anesthesia)
 Intelligence + Motivation + anesthesia
training = Expertise in anesthesia (?)
 CME’s, Refresher Courses, M & M
conferences – maintains “expertise” (?)
 Is every “expert” then a good crisis
manager?
Human Performance
 The concept of “performance” is difficult to
define
– No “Gold Standard”
– Difficult to measure
 Data tends to be subjective
Critical Incidents in the OR
Elements of Core Mental Process
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Observation
Verification
Problem Recognition
Prediction of future states
Decision-making
Action implementation
Reevaluation
Start again with observation
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
Tasks
 Primary tasks
– Completion is dependent on Task Load
 Secondary tasks
– Completion is dependent on the priority of the
Primary Task
Vigilance and Workload
Multi-Tasking in the OR
Prospective Memory
 One’s 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 interruptions:Are
emergency physicians “interrupt-drive” and “multitasking”? Acad Emerg Med 7:1239-1243, 2000
Fixation Errors
 The persistent failure to revise a diagnosis
or plan in the face of readily available
evidence that suggest a revision is
necessary
3 types of Fixation Errors
 “This and only this!”
 “Everything but this!”
 “Everything is OK!”
 “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 60:34-42, 1984
Hazardous Attitudes
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”
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)
Anesthesia and Aviation
Vigilance…
 Both Aviation and
Anesthesia are
describe as…”99%
boredom and 1%
Sheer Terror….”
99% Boredom….
1% Sheer Terror
Interesting Parallels
 Preop Evaluation
 Machine/Equipment
check
 Induction
 Deepening Anesthesia
 Intraop
 Lightening Anesthesia
 Emergence
 Preflight
 Aircraft and preflight
checklist
 Take Off
 Gaining Altitude
 Cruise Altitude
 Descent
 Landing
Dials, Knobs and Alarms
“Cruising, Stormy and Crashing”
Similar Environments…
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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
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
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
Features of Situation Awareness
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Multi-observatioin
Verification
Problem Recognition/Cues
Prediction of Future States
Precompiled Responses/Abstract Reasoning
Action/Implementation
Reevaluation
Fixation Errors
Situational Awareness
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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
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
 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
Crisis Resource Management
 Originally Crew Resource Management
 Problems arise not from poor skills but from
inability to utilize resources effectively
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
Principles of CRM
 Delegation/Assignment of
Tasks/Responsibilities
 Priority Assessment
 Monitoring/Cross checking
 Communication
 Leadership
 Problem Assessment/Avoid Preoccupation
Simulators
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
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
 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)
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.
Safety Reporting Systems
Making Things Safer
 Since the early 1980s, the Anesthesia Patient Safety Foundation
(APSF) has been instrumental in reducing the number of anesthesiarelated 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,
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