The Human Factor – Finessing the White
Bears
Alan Merry
Professor and HOD Anaesthesiology
University of Auckland
Disclosure
Alan Merry has financial interests in
Safer Sleep LLC
Is on the Boards of
Safer Sleep LLC
NZ Health Quality and Safety Commission
Lifebox
ANZCA (ie as a Councillor)
and has received support for research from
ANZCA
WHO
HRC NZ
AFT Pharmaceuticals
Roche Baxter
and 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
Adverse Event Rates from Medical
Record Reviews
Runciman Merry Walton 2006
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
Latent factors
and
Swiss cheese
Reason BMJ 2000
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?
http://en.wikipedia.org/wiki/
File:Edward_lorenz.jpg
Lorenz E American Association for the
Advancement of Science 1972
Problems
• Simple ( baking a cake)
• Complicated (going to the moon)
• Complex (raising a child)
Zimmerman and Glouberman
Cited 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)
Mass
1 mg/ml
Ratio
1 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 nonLuer 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/
“… the rate of postoperative complications and death
were reduced by more than one-third”
Haynes et al NEJM 360 491-9 2009
• 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
Total complications 27.3 – 16.7 per 100 patients
De Vries et al NEJM 2010
In hospital mortality 1.5% - 0.8%
Strategies for Improving Surgical Quality
—
Checklists and Beyond
“…checklists seem to have crossed the
threshold from good idea to standard of
care”
Birkmeyer NEJM 2010
Some Estimates of Anaesthesia Mortality
•
•
•
•
Australia
Zimbabwe
Malawi
Togo
1 in 56000
1 in 3000
1 in 500
1 in 150
Gibbs and Rodoreda Anaesthesia and Intensive Care 2005
McKenzie South African Medical Journal 1996
Heywood et al Annals of Royal College of Surgeons of England 1989
Hansen 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:
Ouro-Bang’na Maman AF Tropical
Doctor 2005 35: 220-22
– Aspiration
– Undetected oesophageal
intubation
– Postoperative hypoxia
– Overdose
– Difficult intubation
• All cases could have been
identified by pulse oximetry
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
We have yet to identify a country that has minimal
monitoring standards for anaesthesia in which pulse
oximetry is not mandatory
Funk et al
Lancet 2010
“HIGHLY
RECOMMENDED:
applicable throughout
any elective procedure,
from patient evaluation
until recovery
(however, immediate
life-saving measures
always take
precedence in an
emergency)”
Global Pulse Oximetry Project
Normal cost
around $750
Global Pulse Oximetry Project
$25
$250
delivered
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
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