Surgical adverse events persist despite several decades of system-based quality improvement efforts, suggesting the need for alternative strategies. Qualitative studies suggest stress-induced ...negative intraoperative interpersonal dynamics might contribute to performance errors and undesirable patient outcomes. Understanding the impact of intraoperative stressors may be critical to reducing adverse events and improving outcomes.
We searched MEDLINE, psycINFO, EMBASE, Business Source Premier, and CINAHL databases (1996–2016) to assess the relationship between negative (emotional and behavioral) responses to acute intraoperative stressors and provider performance or patient surgical outcomes.
Drawing on theory and evidence from reviewed studies, we present the Surgical Stress Effects (SSE) framework. This illustrates how emotional and behavioral responses to stressors can influence individual surgical provider (e.g. surgeon, nurse) performance, team performance, and patient outcomes. It also demonstrates how uncompensated intraoperative threats and errors can lead to adverse events, highlighting evidence gaps for future research efforts.
Since the publication of “Health Information Technology: Fallacies and Sober Realities” in 2010, health information technology (HIT) has become nearly ubiquitous in US healthcare facilities. Yet, HIT ...has yet to achieve its putative benefits of higher quality, safer, and lower cost care. There has been variable but largely marginal progress at addressing the 12 HIT fallacies delineated in the original paper. Here, we revisit several of the original fallacies and add five new ones. These fallacies must be understood and addressed by all stakeholders for HIT to be a positive force in achieving the high value healthcare system the nation deserves. Foundational cognitive and human factors engineering research and development continue to be essential to HIT development, deployment, and use.
•Worsening Health IT usability hinders the achievement of the Quadruple Aim in healthcare.•Clinician burnout is rising exponentially, with poor HIT usability noted as major contributor.•The “Tyranny of Quality Measurement” produced by HIT can be a major distraction to achieving it.•A much greater systematic approach to HFE/SE and UCD in healthcare is imperative.
Sleep Deprivation and Clinical Performance Weinger, Matthew B; Ancoli-Israel, Sonia
JAMA : the journal of the American Medical Association,
02/2002, Volume:
287, Issue:
8
Journal Article
Peer reviewed
Chronic sleep deprivation can affect a doctor's performance, which could increase the risk of a medical error. Although many hospitals have attempted to change resident's work schedules, many interns ...and residents still work 80 hours a week and must work 24 hours straight at least one day a week.
BACKGROUND:We sought to determine whether mannequin-based simulation can reliably characterize how board-certified anesthesiologists manage simulated medical emergencies. Our primary focus was to ...identify gaps in performance and to establish psychometric properties of the assessment methods.
METHODS:A total of 263 consenting board-certified anesthesiologists participating in existing simulation-based maintenance of certification courses at one of eight simulation centers were video recorded performing simulated emergency scenarios. Each participated in two 20-min, standardized, high-fidelity simulated medical crisis scenarios, once each as primary anesthesiologist and first responder. Via a Delphi technique, an independent panel of expert anesthesiologists identified critical performance elements for each scenario. Trained, blinded anesthesiologists rated video recordings using standardized rating tools. Measures included the percentage of critical performance elements observed and holistic (one to nine ordinal scale) ratings of participant’s technical and nontechnical performance. Raters also judged whether the performance was at a level expected of a board-certified anesthesiologist.
RESULTS:Rater reliability for most measures was good. In 284 simulated emergencies, participants were rated as successfully completing 81% (interquartile range, 75 to 90%) of the critical performance elements. The median rating of both technical and nontechnical holistic performance was five, distributed across the nine-point scale. Approximately one-quarter of participants received low holistic ratings (i.e., three or less). Higher-rated performances were associated with younger age but not with previous simulation experience or other individual characteristics. Calling for help was associated with better individual and team performance.
CONCLUSIONS:Standardized simulation-based assessment identified performance gaps informing opportunities for improvement. If a substantial proportion of experienced anesthesiologists struggle with managing medical emergencies, continuing medical education activities should be reevaluated.
BACKGROUND:A nonroutine event is any aspect of clinical care perceived by clinicians or trained observers as a deviation from optimal care based on the context of the clinical situation. The authors ...sought to delineate the incidence and nature of intraoperative nonroutine events during anesthesia care.
METHODS:The authors prospectively collected audio, video, and relevant clinical information on 556 cases at three academic hospitals from 1998 to 2004. In addition to direct observation, anesthesia providers were surveyed for nonroutine event occurrence and details at the end of each study case. For the 511 cases with reviewable video, 400 cases had no reported nonroutine events and 111 cases had at least one nonroutine event reported. Each nonroutine event was analyzed by trained anesthesiologists. Rater reliability assessment, comparisons (nonroutine event vs. no event) of patient and case variables were performed.
RESULTS:Of 511 cases, 111 (21.7%) contained 173 nonroutine events; 35.1% of event-containing cases had more than one nonroutine event. Of the 173 events, 69.4% were rated as having patient impact and 12.7% involved patient injury. Longer case duration (25th vs. 75th percentile; odds ratio, 1.83; 95% CI, 1.15 to 2.93; P = 0.032) and presence of a comorbid diagnosis (odds ratio, 2.14; 95% CI, 1.35 to 3.40; P = 0.001) were associated with nonroutine events. Common contributory factors were related to the patient (63.6% 110 of 173) and anesthesia provider (59.0% 102 of 173) categories. The most common patient impact events involved the cardiovascular system (37.4% 64 of 171), airway (33.3% 57 of 171), and human factors, drugs, or equipment (31.0% 53 of 171).
CONCLUSIONS:This study describes characteristics of intraoperative nonroutine events in a cohort of cases at three academic hospitals. Nonroutine event–containing cases were commonly associated with patient impact and injury. Thus, nonroutine event monitoring in conjunction with traditional error reporting may enhance our understanding of potential intraoperative failure modes to guide prospective safety interventions.
The aim of this study was to investigate the utilization of a portable functional near-infrared spectroscopy (fNIRS) system, the fNIRS Pioneer
, to examine team experience in high-fidelity ...simulation-based crisis event management (CEM) training for anesthesiologists in operating rooms.
Effective evaluation of team performance and experience in CEM simulations is essential for healthcare training and research. Neurophysiological measures with wearable devices can provide useful indicators of team experience to compliment traditional self-report, observer ratings, and behavioral performance measures. fNIRS measured brain blood oxygenation levels and neural synchrony can be used as indicators of workload and team engagement, which is vital for optimal team performance.
Thirty-three anesthesiologists, who were attending CEM training in two-person teams, participated in this study. The participants varied in their expertise level and the simulation scenarios varied in difficulty level. The oxygenated and de-oxygenated hemoglobin (HbO and HbR) levels in the participants' prefrontal cortex were derived from data recorded by a portable one-channel fNIRS system worn by all participants throughout CEM training. Team neural synchrony was measured by HbO/HbR wavelet transformation coherence (WTC). Observer-rated workload and self-reported workload and mood were also collected.
At the individual level, the pattern of HbR level corresponded to changes of workload for the individuals in different roles during different phases of a scenario; but this was not the case for HbO level. Thus, HbR level may be a better indicator for individual workload in the studied setting. However, HbR level was insensitive to differences in scenario difficulty and did not correlate with observer-rated or self-reported workload. At the team level, high levels of HbO and HbR WTC were observed during active teamwork. Furthermore, HbO WTC was sensitive to levels of scenario difficulty.
This study showed that it was feasible to use a portable fNIRS system to study workload and team engagement in high-fidelity clinical simulations. However, more work is needed to establish the sensitivity, reliability, and validity of fNIRS measures as indicators of team experience.
This article explores the impact of recent applications of artificial intelligence on clinical anesthesiologists' decision-making.
Naturalistic decision-making, a rich research field that aims to ...understand how cognitive work is accomplished in complex environments, provides insight into anesthesiologists' decision processes. Due to the complexity of clinical work and limits of human decision-making (e.g. fatigue, distraction, and cognitive biases), attention on the role of artificial intelligence to support anesthesiologists' decision-making has grown. Artificial intelligence, a computer's ability to perform human-like cognitive functions, is increasingly used in anesthesiology. Examples include aiding in the prediction of intraoperative hypotension and postoperative complications, as well as enhancing structure localization for regional and neuraxial anesthesia through artificial intelligence integration with ultrasound.
To fully realize the benefits of artificial intelligence in anesthesiology, several important considerations must be addressed, including its usability and workflow integration, appropriate level of trust placed on artificial intelligence, its impact on decision-making, the potential de-skilling of practitioners, and issues of accountability. Further research is needed to enhance anesthesiologists' clinical decision-making in collaboration with artificial intelligence.
BACKGROUND:When workload is low, anesthesia providers may perform non–patient care activities of a clinical, educational, or personal nature. Data are limited on the incidence or impact of ...distractions on actual care. We examined the prevalence of self-initiated nonclinical distractions and their effects on anesthesia workload, vigilance, and the occurrence of nonroutine events.
METHODS:In 319 qualifying cases in an academic medical center using a Web-based electronic medical chart, a trained observer recorded video and performed behavioral task analysis. Participant workload and response to a vigilance (alarm) light were randomly measured. Postoperatively, participants were interviewed to elicit possible nonroutine events. Two anesthesiologists reviewed each event to evaluate their association with distractions.
RESULTS:At least one self-initiated distraction was observed in 171 cases (54%), largely during maintenance. Distractions accounted for 2% of case time and lasted 2.3 s (median). The most common distraction was personal internet use. Distractions were more common in longer cases but were not affected by case type or American Society of Anesthesiologists physical status. Workload ratings were significantly lower during distraction-containing case periods and vigilance latencies were significantly longer in cases without any distractions. Three distractions were temporally associated with, but did not cause, events.
CONCLUSIONS:Both nurse anesthetists and residents performed potentially distracting tasks of a personal and/or educational nature in a majority of cases. Self-initiated distractions were rarely associated with events. This study suggests that anesthesia professionals using sound judgment can self-manage nonclinical activities. Future efforts should focus on eliminating more cognitively absorbing and less escapable distractions, as well as training in distraction management.
PDF
