Enhancing Point of Care Vigilance Using Computers
Section snippets
Safety and vigilance
For decades, the practice of anesthesiology has defined itself as a leader and advocate for patient safety. An analysis done in 1978 of 359 preventable anesthesia-related accidents revealed that 82% involved human error.1 Most frequently, these errors were associated with inadequate communication, lack of precaution, or distraction.1 Almost 3 decades later, communication failures continue to be a source of significant error in the operating room (OR)2 despite numerous developments in monitoring
Information technology
There are many examples of the use of information technology in the OR suite. Clinical documentation systems record events, procedures, medications, and other items in a patient’s care. Charge capture systems ensure that patients are not charged for items that are not needed while ensuring that facilities have proper accounting of items that are used during a procedure. Electronic digital radiology systems have replaced traditional radiographs and have brought new dimensions to capture,
Situational awareness
Situational awareness is the perception of environmental elements, the comprehension of their meaning, and the prediction of a future state based on those elements and their meaning. In other words, situational awareness is the understanding and awareness of what is happening around you.17 It requires 2 components: information and practitioner vigilance to that information. In the context of anesthesiology, this awareness may consist of what is happening in the OR and the entire surgical care.
OR level situational awareness
The focus on safety and error prevention has lead many institutions to examine the interaction of teams in the OR. Crew management strategies, adopted from the aviation industry, have often been used to train teams of physicians and staff in better methods of interaction to foster a culture and environment of safety in medicine and, specifically, the OR.18, 19 To improve the communication and situational awareness at the staff level, a preoperative time-out has been recommended to improve
Operating suite situational awareness
Situational awareness must extend beyond the OR. Technology can enable OR managers and avoid problems such as tracking patients through the process of surgery. In a traditional system, patient tracking requires the use of manual updates to pen or grease board-based whiteboards. Generally, these boards are located in key management areas such as the OR board and holding room or PACU desks. The only way to determine a patient’s location using this method is to physically visit each location and
Communication
As previously mentioned, issues related to communication are associated with many adverse events.3 Improving communication in a way that enhances the practitioner’s ability to maintain vigilance to important detail is a critical factor in systems design. Traditional communication methodologies require a clinician in one area, for example, a nurse anesthetist in an OR, to identify a pattern or suspected problem before triggering a communication event. That person then typically retrieves a pager
Smart systems and decision support
Automated messages are pieces of information that are sent to a clinician without any user triggering or additional input. An example would be a notification that a patient has entered a room being delivered to a wireless pager. Clinicians can receive this message and judge the timing of their entry to the OR to minimize interruptions and waiting times for a patient who is not yet ready for induction. These messages can be delivered via software to a handheld computer device such as an Apple
Impact on outcomes
Despite significant work on the development of information technology–related systems to support the safety of patients in the OR, little advanced work has been undertaken to prove that these systems have the ability to improve the vigilance or situational awareness of the practitioner or improve the outcome of the patient through a reduction in short- or long-term morbidity and mortality. However, financial studies have supported the use of decision support in terms of providing documentation
Summary
Vigilance and situational awareness remain paramount to patient safety. Coupled with advances in communications, new generations of informatics systems will enhance patient safety and efficiency at the levels of the patient, the OR, and the OR suite. Information provided by these systems will not be in the traditional alarm- or alert-type format. New information will be synthesized from existing raw data and historical databases and will be context specific and rich in value. The demands of an
References (34)
- et al.
The RoboConsultant: telementoring and remote presence in the operating room during minimally invasive urologic surgeries using a novel mobile robotic interface
Urology
(2007) - et al.
Medical team training: applying crew resource management in the Veterans Health Administration
Jt Comm J Qual Patient Saf
(2007) - et al.
Preventable anesthesia mishaps: a study of human factors
Qual Saf Health Care
(2002) - et al.
Communication failures in the operating room: an observational classification of recurrent types and effects
BMJ
(2004) - et al.
To err is human: building a safer health system
(2000) - et al.
Can electronic medical record systems transform health care? Potential health benefits, savings, and costs
Health Aff
(2005) - et al.
Improving safety with information technology
N Engl J Med
(2003) - et al.
An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection
Anesthesiology
(1984) - et al.
Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating room environment
Anesthesiology
(1990) - et al.
Measuring intra-operative interference from distraction and interruption observed in the operating theatre
Ergonomics
(2006)
Investigating interruptions: implications for flightdeck performance
The effect of fatigue on the performance of a simulated anesthetic monitoring task
J Clin Monit
Adoption of anesthesia information management systems by academic departments in the United States
Anesth Analg
Automatic detection and notification of “wrong patient–wrong location” errors in the operating room
Surg Innov
A computerized perioperative data integration and display system
Int J Comput Assist Radiol Surg
Case report of remote anesthetic monitoring using telemedicine
Anesth Analg
Remote presence proctoring by using a wireless remote-control videoconferencing system
Surg Innov
Cited by (9)
Exploring attitudes and opinions of pharmacists toward delivering prescribing error feedback: A qualitative case study using focus group interviews
2016, Research in Social and Administrative PharmacyCitation Excerpt :Without adequate training in communication skills specific to interacting with prescribers, pharmacists could be set up to fail in resolving PEs, limiting their full potential to deliver feedback and function as change agents in patient safety. Feedback should be timely for accurate memory recall and reflection, with feedback closer to the time of the incident having a greater impact on individuals.55–57 Individualized, as opposed to group feedback, delivered face-to-face could allow the facilitator and prescriber time to question and clarify any points, creating a more social interaction and “a full circle of shared responsibility”.27
Medical Informatics in the Perioperative Period
2018, Operating Room Leadership and Perioperative Practice Management, Second EditionElectronic alerts improve immunization rates in two-month-old premature infants hospitalized in the neonatal intensive care unit
2017, Applied Clinical InformaticsWhy providers transfuse blood products outside recommended guidelines in spite of integrated electronic best practice alerts
2015, Journal of Hospital MedicinePaging doctor, emergency?
2014, Anesthesia and AnalgesiaRole of communication systems in coordinating supervising anesthesiologists' activities outside of operating rooms
2013, Anesthesia and Analgesia
Paul St. Jacques, MD, is an inventor of the Vanderbilt Perioperative Information Management system and is a minority equity holder and consultant to Acuitec, LLC, Birmingham, AL, USA.
Brian Rothman, MD, has no relevant financial disclosures.