Human factors training and the systems approach to reducing medical error

Everyone has made a mistake such as locking his or her keys in the car or calling someone by the wrong name. These unintended events, although seemingly significant at the time, pale in comparison to a nurse who accidentally administers the wrong medication or forgets to deliver the proper concentration of oxygen to a patient. In principle, the fundamental human nature of these errors of omission is the same. Nothing is more concerning to a patient than the possibility of becoming a victim of medical error. CRM training addresses the management of critical events in health care with a strong emphasis on human factors. The primary focus is on improvement of human performance in complex work environments to facilitate better decision making under stress, more effective teamwork, and improved patient outcomes.

Human error is an inevitable part of complex and rapidly changing work domains, such as aviation, anesthesiology, and critical care medicine.³ Human error in any discipline can lead to catastrophic outcomes. Major incidents in any industry, such as the crash of the Concorde jet in 2000, gain media interest and prompt public attention and action primarily because of the drama and scope of the event in terms of lives altered or lost. Until recently, human error–related accidents in health care tended to be less visible to the public, primarily because these events usually affect one patient at a time.

Theorists in human factors have identified particular circumstances and error types that can help to train individuals to recognize the signs of errant problem solving. Although human error can never be eradicated, it can certainly be minimized.⁴ Aviation, for example, favors teaching error management techniques rather than an aiming for human perfection. Numerous organizations are dedicated to improving patient safety by funding research endeavors in this area. One such organization, the Anesthesia Patient Safety Foundation, has funded many studies examining human factors and training in the field of anesthesia. Moreover, the National Patient Safety Foundation has broadened the study of human factors to all medical specialties. Both groups believe that further study and advances in training can improve patient outcomes and safety.

Reason⁵ operationalized error into the following three terms: slips, lapses, and mistakes. A slip is defined as an error of execution. It is observable and can simply involve the human action of picking up the wrong syringe or turning the wrong knob on an oxygen flowmeter. A lapse is not observable, but involves the inability of a person to correctly recall information from memory, such as the mixture of a lidocaine drip. Finally, a mistake is defined as an error in planning rather than an error in execution. Here, a nurse may have planned to actively suction secretions from an endotracheal tube during extubation of a patient. Although the execution was technically correct, the lungs were left devoid of oxygen in the process, which was a mistake in planning.

A common misconception is that errors only happen to lazy incompetent individuals who lack vigilance. On the contrary, errors can happen to any individual despite vigilance, motivation, and dedication. When errors occur, blame should not be placed on the individual; rather, a more enlightened view should be embraced—to understand the breakdown in the system and the resulting harm to a patient. Two compelling themes surface from human factors research: (1) humans are prone to err and (2) most errors are not the result of personal inadequacies or carelessness, but instead are the product of defects in the design of health care environmental systems in which the work occurs. An illustrative case follows.

Sarah, an experienced PACU nurse, was well into her double shift by the time the patient arrived in the unit at 2:00 AM. A 36-year-old woman involved in a motor vehicle crash had just undergone an exploratory laparotomy and splenectomy for intraabdominal bleeding. Thirty minutes after the patient’s arrival, an alarm sounded. Sarah noted that the patient’s heart rate was 36 beats/min and dropping. Following unit protocol, Sarah quickly reached into the medication cart for atropine and intravenously administered a 0.4-mg dose. Almost instantly, the patient’s blood pressure soared to 300 mm systolic on the arterial line monitor and the patient went into cardiac arrest. Despite full resuscitative efforts, the patient did not respond.

Later, as Sarah was cleaning up the bedside stand of all the medications used in the code, she found an empty phenylephrine vial. Immediately, Sarah realized that she had inadvertently given the patient a 10-mg bolus of phenylephrine instead of the intended dose of atropine.

A follow-up root cause investigation discovered that the pharmacy had recently stocked phenylephrine next to atropine in the medication drawer. Both the drugs were manufactured by the same company and came in the same sized vials with the same color snap-off caps. The label for atropine was a light red color, but the phenylephrine label was pink. Instead of placing the blame on Sarah, the suggestion was made that pharmacy immediately tag the vials with a black colored A atop the atropine and physically separate the two drugs from one another in the medication cart. The manufacturer was also notified and encouraged to change the labeling system.

Although initially one might question how a nurse could misread or choose not to read the label and give a wrong medication, in retrospect it is easy to see how an experienced nurse could slip while emergently reaching for a medication under conditions of high stress. Such a slip is analogous to a common error among anesthesia providers concerning gas flow meters. At one time, anesthesia gas delivery systems had two similar gas control knobs: one to deliver oxygen and one to deliver nitrous oxide. Slips occurred when anesthesia providers inadvertently turned up the nitrous oxide when they had intended to turn up the oxygen, which resulted in a hypoxic gas mixture being delivered to patients. A human factors approach was chosen to remedy this problem. The oxygen knob was redesigned with deep palpable indentations, whereas the nitrous oxide knob remained smooth. The anesthesia provider then was able to tell by touch alone which knob was in hand. The anesthesia machine was also given a built-in fail-safe mechanism that did not allow the delivery of a hypoxic mixture regardless of how high the nitrous flow was set. This approach to the problem effectively prevented harm to the patient by a hypoxic mixture of gases. Accidents and accident reporting were viewed in these examples as opportunities to design more robust systems to prevent the same type of injury from ever occurring again.

Traditionally, an adverse outcome results in blaming the particular caregiver; however, careful study of the entire system in which the incident occurred usually uncovers multiple factors that contributed to the event.² Lack of training, improper equipment maintenance, poor staffing, or an illegible order transcribed incorrectly can individually or jointly contribute to a critical event. In other words, a cascade of events rather than a single event, often results in an adverse outcome. CRM training advocates the systems approach to adverse outcome analysis. The systems approach seeks answers from a macro perspective to discover the contributing factors. A look at policies and administrative decisions that either supported or derailed a critical incident is a radical departure from the traditional “frame and blame” punitive approach used in medicine. This approach should not be interpreted as lessening the responsibility of the person who made an error, but as gaining a better understanding of why the error occurred; only then can the system be adjusted to better prevent reoccurrence. CRM training strives to make practitioners aware of systemic factors and to work effectively within the context of a large system that might not always support their efforts. The goal of CRM training is to learn from the mistakes of others through an open exchange of information to lessen the contributions of human factors to an adverse event. In this way, students can come to understand the cascade of events that lead to mistakes in a certain situation.

Perianesthesia nurses are at the “sharp end” of the patient encounter; they interface directly with the patient. Many “blunt end” factors, such as the nature of the work, equipment manufacturers, hospital administrations, and other institutional effects, significantly contribute to placing these nurses at that sharp end. When error occurs, it is prudent to examine all causative factors.

Crisis management principles

Many approaches, philosophies, and theories of crisis management exist for use in managing complex industries such as health care. One such approach is described by the acronym ERR WATCH, developed by Fletcher⁶ to help the practitioner recall the eight essential elements of crisis management (Box 4-1). ERR WATCH also serves as a reminder that the goal of crisis management is the reduction of the element of human error in any given situation. The human factors shaping performance are of prime importance. Limitations exist in a health care provider’s ability to quickly and accurately process rapidly changing information during a crisis. When these limitations are understood, many opportunities can be found to improve performance.

The role of PACU nurses is unique in health care delivery. Nurses must not only be familiar with a wide variety of patient conditions and surgical treatments; they must also be educated and prepared to provide care for a multitude of populations, including neonates, small children, adults, and the elderly, all within a single shift. In addition, PACU nurses interact with staff members and physicians from many disciplines and must be able to function with an often unpredictable workload. The following sections discuss these crisis management principles in detail from the perspective of a PACU nurse.

Simulation in CRM training

Simulation is the implementation of artificial representations of complex real-world processes with a sufficient level of fidelity to achieve particular goals.⁹ Simulation imitates real phenomena and processes to capture key characteristics and behaviors of real life events. It is an innovative instructional approach that enhances learning and promotes a sense of empowerment on the part of learners by involving them in the decisions that influence their learning. Through simulation, trainees are challenged in novel ways and take more responsibility in their learning. A critical feature of simulation as a learning tool is that learners have the ability to interact with their surroundings experimentally.⁹ Using high-fidelity simulated environments, educators and trainers can create models of crisis and chaos where the risk to a real patient is absent.

CRM training for PACU personnel incorporates human patient simulators in high-fidelity critical care environments to simulate rare but life-threatening postanesthesia crises, including inability to ventilate, anaphylactic shock, and cardiac arrest, to name a few. Human patient simulators, sometimes referred to as mannequins, are full-body representations of patients that demonstrate physiologic parameters, such as blood pressure, heart rate, airway pressure, oxygen saturation, and central venous and pulmonary pressures. Different models of human patient simulators offer varying degrees of realism, including bleeding, urination, sweating, drooling, pupil constriction and dilation, seizures, chest movement, and peripheral pulses. Standard monitoring equipment is used to display physiologically appropriate measurements of all invasive and noninvasive values. Simulators also have the ability to breathe spontaneously with measurable exhaled carbon dioxide. Furthermore, trainees can assess heart, breath, and bowel sounds. The addition of various props can transform the patient into a full-term parturient, an elderly gentleman, or even a young athlete. Placed within a realistic setting, the human patient simulator becomes lifelike as it converses with trainees via an instructor-speaker microphone.

Human patient simulators come with an accompanying laptop computer and software and are operated by a controller, usually a member of the training team. The controller can steer the human patient simulator to respond to trainee interventions, such as drug and fluid administration, cardiac defibrillation, intubation, and oxygenation. Human patient simulators are highly effective in contributing to the realism necessary to achieve educational objectives.

CRM emphasizes the integration of crisis management principles, including decision making, task management, leadership, communication, situational awareness, and teamwork, in the training of recovery room nurses and team members to manage critical events and crisis situations. Identification and mastering of ideal case management behaviors, including preparation, anticipation, and vigilance, are also a significant goal of CRM training. In addition, factors such as production pressure, problem evolution, and abstract reasoning and their influence on the provider to act efficiently are considered and explored.¹⁰

CRM training is an experiential teaching approach that brings the daunting characteristics of a perianesthesia crisis to life and ultimately intends to improve efficiency, effectiveness, and safety in the delivery of care to surgical patients. Most CRM training courses have a similar structure that incorporates assigned readings that describe basic principles, a course introduction that details the overall concept, an orientation to the simulated critical care environment, and video-taped critical incident scenarios of which the learner is an active participant performing the duties of a PACU team member under the extreme conditions of a postanesthesia emergency. During a simulated scenario, one learner out of the group is randomly selected to be in the “hot seat” as the team leader while the other members of the group participate in various roles as team members. During a CRM training course, the trainee is able to not only actively apply crisis resource management principles during a crisis but also observe other learners applying these same principles while fulfilling other team member roles.

A video-playback, detailed debriefing session, usually facilitated by course faculty, immediately follows the scenario in an adjacent classroom. Debriefing is a discussion among students, guided by faculty, that encourages reflective thought and self review.¹¹ Debriefing is regarded as an integral part of CRM and occurs in a positive, supportive, nonjudgmental, and nonevaluative environment that allows all participants an opportunity to share their experience, offer comments, and discuss concerns.¹¹ The primary goal of debriefing is the discussion of the CRM principles as they relate to the outcome. The discussion is focused on essential crisis management principles such as communication, teamwork, and decision making. Trainees are often surprised at their performances as they view the videotape and are able to scrutinize their interaction with other team members. Most importantly, the group examines CRM strategies that can be used to prevent future errors in similar situations. Most participants complete the course feeling better prepared to navigate the complexity inherent in critical events characteristic of the PACU.

Summary

Much of the existing literature on crisis management comes from the field of aviation psychology, air traffic control, and military operations. In an effort to improve quality and safety in health care, formal training in crisis management has been developed and embraced by many disciplines. CRM in health care incorporates concepts such as situation awareness and human error, to ultimately improve provider performance and promote patient safety.

Technical knowledge and skills alone are not adequate for functioning in the complex environment of critical care. Patients today are sicker than ever before. With this increased patient acuity also comes an increasing number of critical events that need prompt and accurate management. Each problem has many possible outcomes that depend largely on the actions or inactions of caregivers. Every patient deserves to have well-trained and knowledgeable care providers who can manage the ordinary events associated with recovery from anesthesia as well as the unexpected ones. CRM training and simulation offer a new approach to help PACU nurses meet these challenges successfully. Like the patients for whom they care, health care professionals are human, and humans are imperfect, which is something that cannot be changed. Through advanced training techniques such as CRM and the use of high-fidelity simulation technologies, perianesthesia nurses can be more prepared for life-threatening emergencies, mitigate the number of preventable mishaps, and better contribute to the overall well-being of the patients for whom they provide care.