# Presentation: 107136

## Spotlight Case September 2003

**Infant Paralyzed for Intubation Before Airway Materials Ready**

## Source and Credits

- This presentation is based on the Sept. 2003 AHRQ WebM&M Spotlight Case in Pediatrics
- See the full article at _[http://webmm.ahrq.gov](http://webmm.ahrq.gov/)_
- CME credit is available through the Web site
- Commentary by: **Matthew B. Weinger, MD, **University of California, San Diego;** George T. Blike, MD, **Dartmouth College of Medicine
- Editor, AHRQ WebM&M: Robert Wachter, MD
- Spotlight Editor: Tracy Minichiello, MD
- Managing Editor: Erin Hartman, MS

## Objectives

*	**At the conclusion of this educational activity, participants should be able to:*
- Understand and apply a structured method of human factors case analysis
- Describe the key components of effective teamwork
- Understand the importance of and the barriers to effective interpersonal communication
- Design effective interventions to address deficiencies in teamwork and communication

## Case: Infant Paralyzed 

*A 17-month-old baby girl in the PICU developed acute respiratory failure. While setting up the laryngoscope and endotracheal tube, the PICU physician gave a verbal order for atropine, etomidate, and rocuronium. Shortly thereafter, but prior to intubation, the infant acutely desaturated. She was immediately intubated and her respiratory status was stabilized.*

## Case (cont.): Infant Paralyzed

*Upon review of the event, the team discovered that the nurse was new to the PICU. She had not realized the medication was a paralytic agent, and thus administered it before the intubation tray was ready, resulting in the infant’s desaturation. The physician who ordered the medication had not indicated the timing of administration nor that the medication was to be drawn up but not given until later.*

## Five Stages in Reviewing an Error:  Human Factors Approach

- Contact event reporter to gather complete facts of the event (what/when/how, etc.)
- Interviews of participants are often necessary
- Review incident for management problems
- Did care deviate beyond safe limits?
- If so, did deviation have potential to cause patient harm?

## 3.	Perform “contributory factor analysis” using a checklist of items 
4. Prioritize contributory factors that pose significant threat based on the risk analysis matrix
5. Design and implement countermeasures to actively “manage” this and similar errors

- 4. Prioritize contributory factors that pose significant threat based on the risk analysis matrix
- 5. Design and implement countermeasures to actively “manage” this and similar errors

**Five Stages in Reviewing an Error:  Human Factors Approach**

## Patient Factors
Patient condition
Clinician–patient communication
Availability/accuracy of test results
Task Factors
Task design and clarity of structure
Availability and use of protocols

- Patient condition
- Clinician–patient communication
- Availability/accuracy of test results
- Task Factors
- Task design and clarity of structure
- Availability and use of protocols

**Contributory Factor Analysis**

**Notes:**
Please refer to table in spotlight case for CFA of this case

## Practitioner Factors
Knowledge, skills, rules
Attention
Strategy
Motivation & attitude
Physical or mental health

- Knowledge, skills, rules
- Attention
- Strategy
- Motivation & attitude
- Physical or mental health

**Contributory Factor Analysis (cont.)**

## Team Factors
Verbal or written communication
Supervision, seeking help
Team structure and leadership
Working Conditions
Staffing levels, skill mix, workload
Availability and maintenance of equipment
Administrative and management support

- Verbal or written communication
- Supervision, seeking help
- Team structure and leadership
- Working Conditions
- Staffing levels, skill mix, workload
- Availability and maintenance of equipment
- Administrative and management support

**Contributory Factor Analysis (cont.)**

## Organization/Management
Financial resources
Goals, policies, and standards
Safety culture and priorities
National/Public Health Factors
Economic and regulatory issues
Health policy and politics
Medical liability

- Financial resources
- Goals, policies, and standards
- Safety culture and priorities
- National/Public Health Factors
- Economic and regulatory issues
- Health policy and politics
- Medical liability

**Contributory Factor Analysis (cont.)**

## Risk Analysis Matrix

- Simplified risk analysis matrix shows the relationship between severity of outcome of an event and likelihood of its reoccurrence. In general, events in the intermediate to high risk and moderate to severe severity are those which require active efforts to prevent or mitigate.

*Reason J. Human Error. 1990*

**Notes:**
	Reason J. Human Error. Cambridge: Cambridge University Press; 1990. 

## Contributory Factor Analysis for This Case

- Task Factors
- Intubation task steps not explicit
- No intubation protocol in place
- Practitioner Factors
- Inexperienced RN, did not know medications
- Decreased attention of supervising MD
- Verbal order—no briefing on roles/responsibilities

## Contributory Factor Analysis for This Case (cont.)

- Team Factors
- Verbal order statement not complete
- Inexperienced RN did not seek help
- Team structure unclear
- Working Conditions
- RN shortage has led to increased hiring of younger, less experienced nurses
- Inadequate training of nurses on high-risk units

## Effective Team Work: The 5 “C’s”

- Common Goal
- Every team member shares the short- and long-term goals of the team/organization
- Commitment
- Every team member is committed to attaining the goals
- Competence
- Every team member has knowledge, skills, behaviors, and attitudes necessary to perform his or her role

*Katzenbach JR, Smith DK. The Wisdom of Teams. 1993.*

**Notes:**
Katzenbach JR, Smith DK. The Wisdom of Teams: Creating the High Performance Organization. Cambridge, MA; 1993.

## Effective Team Work: The 5 “C’s”

- Communication
- Team members communicate effectively/efficiently with each other, the patient, and other parties
- Coordination
- Team members work together efficiently and effectively

*Katzenbach JR, Smith DK. The Wisdom of Teams. 1993.*

**Notes:**
Katzenbach JR, Smith DK. The Wisdom of Teams: Creating the High Performance Organization. Cambridge, MA; 1993.

## Evidence for Communication Failures

- Poor communication between team members  accounted for 37% of all errors in a 4-month period of observation in critical units
- Communication failures contributed to 16% (20/98) operating room events in anesthesia safety research
- Almost 90% occur in last 2-4 hours of case

*Donchin Y, et al. Crit Care Med. 1995;23:294-300.*

**Notes:**
Donchin Y, Gopher d, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995;23:294-300.

## Evidence for Communication Failures (cont.)

- During 700 hours of direct observation, communication errors accounted for 11% of 118 operating room events
- At Dartmouth Hitchcock Medical Center, failures of team communication were identified in 61% of the 42 events reviewed over the past 4 years

**Notes:**
(Weinger, et al., unpublished work), 

## Taxonomy of Communication Failures

- Failure of message transmission
- Failure of message reception
- Failure of message acknowledgment

## Failure of Message Transmission

- Failure to inform
- ICU doctor fails to inform anesthesiologist doing nasal intubation that patient is anticoagulated
- Delayed transmission
- Laboratory test results relevant to therapeutic decision “lost” for several hours

## Failure of Message Transmission (cont.)

- Wrong information transmitted
- “Mrs. Jones had an MI” when it was in fact Mr. Smith
- Ambiguous or incomplete information transmitted
- Physician states “give rocuronium” without specifying dose, route, and/or timing

## Failure of Message Reception

- Message not heard
- Noisy environment prevents team from hearing instructions
- Wrong information heard
- RN heard “give epinephrine” instead of “ephedrine”
- Information misunderstood
- Pharmacist thought order was for different patient
- Failure to act on message
- Distraction leads to delay or failure to give requested drug

## Failure of Message Acknowledgment

- Failure to acknowledge receipt
- Anesthesiologist fails to acknowledge surgeon’s request that heparin be administered
- Failure to acknowledge understanding
- Team member responds with “uh-huh” rather than explicit read-back of instructions given
- Failure to state when action taken
- Requested action acknowledged, but either not taken or delayed and not stated when completed

## Why do communication failures occur?

- Current healthcare curricula largely fail to cover interpersonal influence, group dynamics, organizational behavior, negotiation, or conflict resolution
- Care is provided by teams of individuals with diverse educational and cultural backgrounds
- Non-verbal communication has strong influence
- Up to 50% of “message” conveyed in non-verbal behavior (facial expression, body posture, movement, eye contact, etc.)

*Birdwhistell RL. Kinesics and Context. 1970. **Mehrabian A. Silent Messages. 1981.*

**Notes:**
Birdwhistell RL. Kinesics and Context: Essays on Body Motion Communication. Philadelphia: University of Pennsylvannia Press; 1970.

Mehrabian A. Silent Messages: Implicit Communication of Emotion and Attitudes. Belmont, CA: Wadsworth Publishing Co.; 1981.

## Key Components of Clinical Competence

- Knowledge application
- Problem-solving skills
- Decision-making capacity
- Effective communication
- Team work
- Adaptability

*Dreyfus HL, et al. Mind Over Machine. 1986.*

**Notes:**
Dreyfus HL, Dreyfus SE, Athanasiou T. Mind Over Machine: The Power of Human Intuition and Expertise in the Era of the Computer. New York: The Free Press; 1986.

## Situation awareness
Preparedness
Knowledge alone is not sufficient!

- Preparedness
- Knowledge alone is not sufficient!

*Gaba DM, et al. Hum Factors. 1995;37:20-31.**Endsley MR. Hum Factors. 1995;37:65-84.*

**Key Components of Clinical Competence**

**Notes:**
Endsley MR. Measurement of situation awareness in dynamic systems. Human Factors. 1995;37:65-84.

Gaba DM, Howard SK, Small SD. Situation awareness in anesthesiology. Human Factors. 1995;37:20-31.

## Crew Resource Management (CRM)

- Modality used in aviation industry to train team members applied to medicine
- Anesthesia Crisis Resource Management Training (ACRM)
- Uses high-fidelity patient simulation to recreate complexity of clinical care
- Re-creates incidents that provoke performance failures in a safe environment
- Videotapes analyzed later to identify performance failures and structure interventions

*Gaba DM, et al. Crisis Management in Anesthesiology. 1994. *

**Notes:**
Gaba DM, Fish K, Howard SK. Crisis Management in Anesthesiology. New York: Churchill Livingstone; 1994. 

## Crew Resource Management (cont.)

- Team members learn critical teamwork behaviors:
- Task allocation
- Read-backs
- Closed-loop communication
- Role clarification
- Identifying individual responsibilities

## Video Simulation

- Video simulations demonstrate examples of both “miscommunication” and “good communication”
- _[Click here ](http://webmm.ahrq.gov/spotlightcases.aspx?ic=29#video)__to view videos online*_
**You must be connected to the internet to see the videos*

**Notes:**
The first video is titled “Poor Communication” and might be what happened in this case, with the caveats described above. The second video is titled “Good Communication”  and is meant to show how communication might have been different if the clinicians had all participated in a team-based Crisis Resource Management Course. Take particular notice of how the ICU physician and nurse communication differ (both in terms of confirming that the order was understood and seeking clarification of intent) as you watch the two 3-minute videos.

## Take-Home Points

- When evaluating medical errors, application of the Contributory Factor Analysis can prioritize problem areas and target resources for quality improvement efforts
- Medical errors are increasingly due to failures in communication and teamwork
- Effective teamwork requires the “5 C’s”
- Common goal, Commitment, Competence, Communication, Coordination

## Take-Home Points (cont.)

- Traditional training models (lectures, tapes) are not sufficient to prevent these errors
- Isolated training of different care provider types contributes to the difficulties in communication
- CRM, video simulators, role-plays, other innovations will be needed to improve these areas