A Theoretical Model of Flow Disruptions for the Anesthesia Team During Cardiovascular Surgery.
Journal
Journal of patient safety
ISSN: 1549-8425
Titre abrégé: J Patient Saf
Pays: United States
ID NLM: 101233393
Informations de publication
Date de publication:
01 Sep 2021
01 Sep 2021
Historique:
pubmed:
6
7
2017
medline:
25
11
2021
entrez:
6
7
2017
Statut:
ppublish
Résumé
This investigation explores flow disruptions observed during cardiothoracic surgery and how they serve to disconnect anesthesia providers from their primary task. We can improve our understanding of this disengagement by exploring what we call the error space or the accumulated time required to resolve disruptions. Trained human factors students observed 10 cardiac procedures for disruptions impacting the anesthesia team and recorded the time required to resolve these events. Observations were classified using a human factors taxonomy. Of 301 disruptions observed, interruptions (e.g., those events related to alerts, distractions, searching activity, spilling/dropping, teaching moment, and task deviations) accounted for the greatest frequency of events (39.20%). The average amount of time needed for each disruption to be resolved was 48 seconds. Across 49.87 hours of observation, more than 4 hours were spent resolving disruptions to the anesthesia team's work flow. By defining a calculable error space associated with these disruptions, this research provides a conceptual metric that can serve in the identification and design of targeted interventions. This method serves as a proactive approach for recognizing systemic threats, affording healthcare workers the opportunity to mitigate the development and incidence of preventable errors precedently.
Identifiants
pubmed: 28678115
pii: 01209203-202109000-00020
doi: 10.1097/PTS.0000000000000406
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
e534-e539Informations de copyright
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Déclaration de conflit d'intérêts
The authors disclose no conflict of interest.
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