Effective Management of Anaesthetic Crises

Crisis management

* Personal and team based skills essential
* Lack of skills - morbidity and mortality
* Problem solving
* Cognitive and communication process which can be taught and learned
* Difficult under pressured and changing enviroment

Levels

* Procedural control
* Supervisory control
* Resource management

Human Error

* Commonest cause of patient incident
* Individual or system level approaches

Individual blame - Reason's Taxonomy

* Rules, skills, knowledge based errors
* Aims to suppress variability in human performance
* Ignores system / environment in which complex tasks are undertaken
* Perpetuates human error myths

Human error myths

* Errors are intrinsically bad
* Bad people make bad errors
* Errors are random and highly variable
* Practice makes perfect
* Errors of highly trained people are rare
* Errors of highly trained people are enough to cause bad outcomes
* Easier to change people than situations

Systems Error

* Expects errors will occur due to:
human variability
Failure of environment or organisation
* Active failures
Slips, lapses, procedural violation by people indirect patient contact
* Latent conditions
Inevitable, invisible system states
Right time and place
People or groups breach system defences

High Reliability Organisations

* Power generation, air traffic control, aircraft carrier
* Dangerous and complex tasks
* Multiple defences to error
* Culture of maximal safety by personnel

Latent Conditions

* Rostering
* Shift work policies
* Production pressure acceptance
* Interact with individuals as “performance shaping factors”
Inexperience, fatigue, ambient noise, illness
Drug abuse
Hazardous attitudes

Hazardous Attitudes

* Anti authority
* Impulsiveness
* Invulnerability
* Macho (self control)
* Resignation
All have underlying complex psychology
Affect decision making skills

Anaesthesia Decision Making

* Associated risk
* Dynamic stressful environment
* Negative impact of factors and attitudes
Eg feelings of impulsiveness, invincibility and self control increase with fatigue

Conclusions

* Role of error accepted in anaesthesia
* Specialty prominent in patient safety measures
* QAHCS study suggests 18000 patients per year suffer an iatrogenic adverse advent that is either an underlying or contributing cause of death
* We are individually fairly reliable but exist in a system that has low reliability
* Anaesthesia delivery
Interplay of environmental system and human factors
* Demands recognition and pursuit of
Improved crisis management skills
Greater understanding of human error
Non punitive approach to system error - aim to learn not blame