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

Conclusions

• 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