Quality and safety in anesthesia and perioperative care

321 Pages·2016·5.67 MB·English

by  Keith J. Ruskin

QUALITY AND SAFETY
IN ANESTHESIA AND
PERIOPERATIVE CARE

QUALIT Y AND SAFET Y
IN ANESTHESIA AND
PER IOPER ATI V E CAR E
EDITED BY
KEITH J. RUSKIN, MD
Professor of Anesthesia and Critical Care
University of Chicago
Chicago, Illinois
MARJORIE P. STIEGLER, MD
Associate Professor of Anesthesiology
University of North Carolina
Chapel Hill, North Carolina
STANLEY H. ROSENBAUM, MD
Professor of Anesthesiology, Medicine, and Surgery
Yale University School of Medicine
New Haven, Connecticut
1
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Library of Congress Cataloging- in- Publication Data
Names: Ruskin, Keith., editor. | Stiegler, Marjorie P., editor. | Rosenbaum, Stanley H., editor.
Title: Quality and safety in anesthesia and perioperative care /
edited by Keith J. Ruskin, Marjorie P. Stiegler, Stanley H. Rosenbaum.
Description: Oxford ; New York : Oxford University Press, [2016] |
Includes bibliographical references and index.
Identifiers: LCCN 2016006863 (print) | LCCN 2016007645 (ebook) | ISBN 9780199366149 (alk. paper) |
ISBN 9780199366156 (e-book) | ISBN 9780199366163 (e-book) | ISBN 9780199366170 (online)
Subjects: | MESH: Medical Errors—prevention & control | Patient Safety—standards |
Anesthesiology—standards | Perioperative Care—standards | Patient Care Team—standards
Classification: LCC RD82 (print) | LCC RD82 (ebook) | NLM WX 153 | DDC 617.9/60289—dc23
LC record available at http://lccn.loc.gov/2016006863
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In memory of Lloyd Leon Ruskin
זיכרונו לברכה

CONTENTS
Foreword  ix PART II: Clinical Applications
Preface  xiii
9. Adverse Event Prevention
Acknowledgments  xv
and Management  131
Contributors  xvii
Patrick J. Guffey
and Martin Culwick
PART I: Scientific Foundations 10. Complex Systems and Approaches
1. Patient Safety: A Brief History  3 to Quality Improvement  143
Loren Riskin and Alex Macario
Robert K. Stoelting
11. Crisis Resource Management and
2. Cognitive Load Theory
Patient Safety in Anesthesia Practice  158
and Patient Safety  16
Amanda R. Burden,
Elizabeth Harry
Jeffrey B. Cooper,
and John Sweller
and David M. Gaba
3. Errors and Violations  22
12. Quality in Medical Education  167
Alan F. Merry
Viji Kurup
4. The Human- Technology Interface  48
13. Regulating Quality  174
Frank A. Drews
Robert S. Lagasse
and Jonathan R. Zadra
14. Creating a Quality
5. Deliberate Practice and
Management Program  189
the Acquisition of Expertise  66
Richard P. Dutton
Keith Baker
15. Health Information Technology
6. Fatigue  80
Use for Quality Assurance
Michael Keane
and Improvement  200
7. Situation Awareness  98 Christine A. Doyle
Christian M. Schulz
16. Safety in Remote Locations  213
8. Creating a Culture of Safety  114 Samuel Grodofsky, Meghan
Thomas R. Chidester Lane- Fall, and Mark S. Weiss
viii Contents
17. Medication Safety  228 20. Managing Adverse Events:
The Aftermath and the Second
Alan F. Merry
Victim Effect  269
18. Operating Room Fires
Sven Staender
and Electrical Safety  242
Stephan Cohn
Index  275
and P. AlLan Klock, Jr.
19. Disruptive Behavior: The Imperative
for Awareness and Action  254
Sheri A. Keitz and David J. Birnbach
FOREWORD
Although safety issues confront many indus- community. Human factors is an applied dis-
tries, the most complex challenges— by far— cipline that draws upon the cognitive, social,
lie in patient safety. As Lewis Thomas1 pointed physiological, and engineering sciences to
out, nineteenth- century physicians could in- understand the conditions that affect human
fluence the outcome of illness only modestly at performance and to devise ways to enhance
best. Advances in medical science and technol- and protect that performance. Medical safety
ogy now enable extraordinary interventions researchers have particularly drawn on the
that can dramatically improve patients’ lives. contributions that human factors science has
On the other hand, highly specialized proce- made to commercial aviation safety, through
dures that are designed to intervene precisely concepts such as situation awareness, crew
in intricate physiological processes are inher- resource management, threat and error man-
ently vulnerable to adverse events and are ter- agement, high- reliability organizations, and
ribly unforgiving of errors. Moreover, patients safety culture. Procedures such as checklists
who seek medical care often have multiple dis- and explicit practices for data monitoring have
ease processes, further increasing their vul- also emerged from aviation, as have principles
nerability to mishap. for designing equipment interfaces such as
Modern healthcare systems are extremely the visual displays in modern airline cockpits
complex, involving many individual profes- that help pilots maintain situation awareness.
sionals with different kinds of expertise who These concepts, procedures, and design prin-
must work together as teams. Diverse organ- ciples can be adapted to improve patient safety.
izational factors influence how effectively in- Human factors science has also improved
dividuals and teams are able to do their work. safety in many industries by chipping away at
Every action in the extended healthcare proc- long- standing but misleading concepts of the
ess provides opportunities for things to go nature of the errors made by expert profession-
wrong, adversely affecting patient outcome. als. For many years, it was assumed that if a
By the time the Institute of Medicine’s 1999 well- trained professional could normally per-
report, To Err Is Human,2 galvanized public form some task without difficulty, then errors
awareness of the extent of iatrogenic harm, an- in the performance of that task in an accident
esthesiologists had already established them- sequence must be the “cause” of that accident.
selves as leaders in the medical community’s This philosophy implies that the professional
search for ways to improve patient safety. who made the error is deficient in some way.
As part of that search, the medical com- But in reality, accidents almost always involve
munity has examined ways in which other the confluence of many factors, and the in-
industries have improved their safety, and this teraction of those factors is partly a matter of
has led to collaboration with the human factors chance. Errors are only part of this confluence,