Human factors in anaesthetic crisis

Table 1 Human factors in pediatric anaesthesia incidents by Marcus[15] (modified)

Human factors	Cognitive mechanism
Error of judgement	Rule or knowledge
Failure to check	Violation
Technical failures ok skill	Skill
Inexperience	Knowledge
Inattention/distraction	Skill
Communication	Latent
Poor preoperative assessment	Rule or knowledge
Lack of care	Skill
Drug dosage slip	Skill
Teaching	Skill
Pressure to do the case	Latent

Table 2 Cognitive de-biasing strategies[10]

Plan	Action	Example
Develop insight or awareness	Illustration of the errors caused by biases in the cognitive thinking process with the help of clinical examples leads to a better understanding and awareness	The case of intraoperative low oxygen saturations presumed to be due to cold fingers, when the actual cause was endo-bronchial intubation
Consider alternatives	Forming a habit wherein alternative possibilities are always looked into	Continuing with the above example, establishing a habit of looking for other (true) causes of low oxygen saturation, rather than simply blaming the cold fingers could direct the anaesthetist to look for other causes including a possible endotracheal intubation
Metacognition (strategic knowledge)	Emphasis on a reflective approach to problem solving	Knowing when and how to verify data is a good example of Strategic Knowledge
Decreased reliance on memory	Use of cognitive aids, pneumonics, guidelines and protocols protects against errors of memory and recall	Use of guidelines and protocols in the use of intralipids to treat Local Anaesthetic toxicity
Specific training	Identify specific flaws and biases and providing appropriate training to overcome these flaws	Early recognition of a “cannot intubate, cannot ventilate” scenario to guard against fixation errors
Simulation exercises	This is focussed at the common clinical scenarios prone for errors and emphasis on prevention of these errors secondary to human factors	Use of simulation training for difficult airway management
Cognitive forcing strategies	A coping strategy to avoid biases in particular clinical situations is often reflected in the practice of experienced clinicians	Checking for the availability of blood products as a routine ritual prior to the start of major surgery every single time can be considered as strategy to avoid
Minimize time pressures	Allowing adequate time for decision making rather than rushing through	Allowing time to check on patients airway prior to induction can help avoid surprises in airway management
Accountability	Establish clear accountability and follow up for decisions made	A decision to use frusemide intra operatively is followed up by checking the serum potassium levels
Feedback	Giving a reliable feedback to the decision maker, so that the errors are immediately appreciated and corrected	Junior anaesthetist reminding the senior of the allergy to a certain antibiotic, when the antibiotic is about to be administered

Table 3 Practical strategies to prevent human errors

Practical strategies to prevent human errors
Checklists
Resuscitation training or simulations
Managing Stress
Dealing with Fatigue
Standard operating procedures or protocols or guidelines
Team work with good communication

Table 4 The systems engineering initiative for patient safety model components and elements[41] (modified)

	Components	Elements
Work system	Person	Skills, knowledge, motivation, physical and psychological characteristics
	Organization	Organizational culture and patient safety culture, work schedules, social relationships
	Technology and tools	Human factors characteristics of technologies and tools
	Tasks	Job demands, job control and participation
	Environment	Layout, noise and lighting
Process	care process	Information flow, purchasing, maintenance and cleaning
Outcomes	Employee and organizational outcomes	Job satisfaction, stress and burnout, employee safety and health, turnover
	Patient outcomes	Patient safety, quality of care