Improving Patient Safety During Critical Events Using The Science of Human Factors

Although anesthesia related-mortality is currently less than 1/100:000, intraoperative critical events can still lead to undesirable outcomes.(1) Increased attention is being paid to the use of the science of human factors to create tools to improve clinician performance during these events. Asking clinicians about their needs during these events, in multiple surveys, revealed consistent results - clinicians would access a cognitive aid to find a drug dose or additional treatment ideas, make sure that no important actions were missed, or to obtain help in making a differential diagnosis. Our research group created novel critical event cognitive aids to facilitate accessing information for these specific reasons - a use that we call `sampling` (Figure 1). Human factors principles incorporated included: consistency in where similar information was located on each checklist, small sections containing similar information to improve information processing, and minimal distractions. The goal was to create cognitive aids that lead to quicker finding of needed information during critical events, and our current research with anesthesia clinicians with subjects showed that this goal was met.

Resources: 1) Li G, Warner M, Lang BH, et al. Epidemiology of anesthesia-related mortality in the United States, 1999-2005. Anesthesiology 2009;110(4):759-65. 2) Burian, B., Clebone, A., Dismukes, R., Ruskin, K. More than a Tick Box: Medical Checklist Development, Design, and Use. Anesthesia and Analgesia, Epub ahead of print doi: 10.1213/ANE.0000000000002286