The Human Factor – Finessing the White Bears Alan Merry Professor and HOD Anaesthesiology

The Human Factor – Finessing the White Bears

Alan MerryProfessor and HOD Anaesthesiology

University of Auckland

DisclosureAlan Merry has financial interests in

Safer Sleep LLCIs on the Boards of

Safer Sleep LLCNZ Health Quality and Safety Commission

LifeboxANZCA (ie as a Councillor)

and has received support for research from ANZCAWHO

HRC NZAFT Pharmaceuticals

Roche Baxterand others

Today…

• A story of an error in anaesthesia• Systems, human error and why things go wrong,

extending the Reason model with some new ideas

• Some recent guidelines and possible solutions• Acknowledge Atul

Gawande, Angela Enright, Iain Wilson, Rob McDougal, Peter Kempthorne and others

Medication Errors in Anaesthesia

• About 1 in every 1000 administrations (≈135 anaesthetics)

• 10 000 drug errors reported in the UK in 2006 25 deaths and 28 cases of severe harm

Webster Merry et al Anaesth Intens Care 2001

NPSA “Promoting safer use of injectable medicines” 2007

Runciman Merry Walton 2006

Adverse Event Rates from Medical Record Reviews

NEJM Nov 2010

Approaches to Cognitive Psychology

• Experimental cognitive psychology– experiments on healthy individuals

• Cognitive neuropsychology– studying impairment in brain damage

• Computational cognitive science– modelling

• Cognitive neuroscience– imaging

Reason BMJ 2000

Latent factors and

Swiss cheese

Errors

• Experts make errors• Not carelessness• Deterrence useless• Medical practice is challenging

Errors - Definition

When you are trying to do the right thing but you actually do the wrong thing

Focus on process not outcome

Violations

• Element of choice• May be carelessness• Deterrence may be effective

Violations

• Element of choice• May be carelessness• Deterrence may be effective

• Not always reprehensible• Systems double-bind

Classification of Error

• Action failure• Skill-based (slips and lapses)• Technical (dural tap)

• Decision or planning failure• Rule-based • Knowledge-based

Classification of Error

• Action failure• Skill-based (slips and lapses)• Technical (dural tap)

• Decision or planning failure• Rule-based • Knowledge-based Errors of reasoning

Chaos Theory:Deterministic vs Random Systems

Predictability: Does the Flap of a Butterfly’s

Wings in Brazil set off a Tornado in Texas?

Lorenz E American Association for the Advancement of Science 1972http://en.wikipedia.org/

wiki/File:Edward_lorenz.jpg

Problems

• Simple ( baking a cake) • Complicated (going to the moon)• Complex (raising a child)

Zimmerman and GloubermanCited in Gawande The Checklist Manifesto 2010

How We Think

How We Think

Automatic System• Uncontrolled• Effortless• Associative• Fast• Unconscious• Skilled

Reflective System• Controlled• Effortful• Deductive • Slow• Self-aware• Rule-following

Thaler and Sunstein Nudge 2008

Wegner DM et al Psychological Science 1998

Gibbs N Anaesth Intensive Care 2005

Time for a New Paradigm: STPC

• Standardization (drugs, concentrations, equipment)• Technology (drug identification and delivery, automated

information systems)• Pharmacy (satellite pharmacy, premixed solutions and

prefilled syringes whenever possible)• Culture (recognition and reporting of drug errors to reduce

recurrences)

Mass1 mg/ml

Ratio1 in 1000

Wheeler D et al Annals of Internal

Medicine 2008

“Both systems scored significantly lower than standard equipment for overall performance of spinal and epidural procedures, although the performance of non-Luer devices was mostly rated ‘adequate’ or better”“Both non-Luer connectors could cross-connect with one or more Luer connectors”

The Amsterdam Urinals

Choice Architecture“It turns out that, if you give men a target, they can’t help but aim at it”

http://nudges.wordpress.com/the-amsterdam-urinals/

Haynes et al NEJM 360 491-9 2009

“… the rate of postoperative complications and death were reduced by more than one-third”

• 108 VA facilities: 182 409 sampled procedures 2006-8• Briefings debriefings and checklists• 74 vs 13: mortality RR

0.82 (0.76-0.91) vs 0.93 (0.80-1.08) (18% vs 7%)

Neily J et al JAMA 2010

De Vries et al NEJM 2010

De Vries et al NEJM 2010

Total complications 27.3 – 16.7 per 100 patientsIn hospital mortality 1.5% - 0.8%

Strategies for Improving Surgical Quality —

Checklists and Beyond

Birkmeyer NEJM 2010

“…checklists seem to have crossed the threshold from good idea to standard of

care”

Some Estimates of Anaesthesia Mortality

• Australia 1 in 56000• Zimbabwe 1 in 3000• Malawi 1 in 500• Togo 1 in 150

Gibbs and Rodoreda Anaesthesia and Intensive Care 2005

McKenzie South African Medical Journal 1996Heywood et al Annals of Royal College of Surgeons of

England 1989Hansen et al Tropical Doctor 2000

Ouro-Bang'na et al Tropical Doctor 2005

Togo: Avoidable Anaesthetic Mortality

• 74% of anaesthetic deaths due to respiratory causes:– Aspiration– Undetected

oesophageal intubation– Postoperative hypoxia– Overdose– Difficult intubation

• All cases could have been identified by pulse oximetry

Ouro-Bang’na Maman AF Tropical Doctor 2005 35: 220-22

Ouro-Bang'na et al Tropical Doctor 2005(Slide modified from Walker I 2008)

77 700 ORs worldwide

and 31.5 million

operations per year without

oximetry

Funk et al Lancet 2010

77 700 ORs worldwide

and 31.5 million

operations per year without

oximetry

Funk et al Lancet 2010

We have yet to identify a country that has minimal monitoring standards for anaesthesia in which pulse

oximetry is not mandatory

“HIGHLY RECOMMENDED: applicable throughout any elective procedure,from patient evaluation until recovery (however, immediate life-saving measures always takeprecedence in an emergency)”

Global Pulse Oximetry Project

Normal cost around $750

Global Pulse Oximetry Project

$250 delivered$25

Education

• A huge challenge• Linked to local agreements and philosophy of

sustainable change• One size will not fit all needs• Should address physiology and decision

making

Educational CDROM – 6 Languages

• Training and practice• Appropriate equipment,

facilities and support• Intelligent design• Process tools (including

checklists and well designed simple algorithms)

• Experience, experience, experience

www.lifebox.org