The aviation industry has an admirable safety record built on simulation training and the use of manuals and checklists to reduce errors. Anesthesiology is following suit through the development of cognitive aids, which David M. Gaba, M.D., discussed during yesterday’s Pierce Lecture at the national ASA meeting.
“Human memory and computation is a limited resource, especially under stress and especially when the unexpected happens,” said Dr. Gaba, who presented the Ellison C. Pierce Jr., M.D., Patient Safety Memorial Lecture, “Competence and Teamwork Are Not Enough: The Value of Cognitive Aids.”
Dr. Gaba opened the lecture by talking about the safety efforts of his mentor, the late Dr. Pierce, who was affectionately known as “Jeep.” Dr. Gaba is Associate Dean for Immersive and Simulation-based Learning at Stanford University and Staff Anesthesiologist and Director of the Patient Simulation Center of Innovation at the VA Palo Alto Health Care System.
“Precomputation is when you do computation ahead of time and don’t have to do that in real time,” Dr. Gaba said, adding that to-do lists and checklists are examples of precomputation. These are common tools used by pilots, astronauts and nuclear reactor operators.
“The perception is that health care is unique and not like other lines of work, that doctors are ‘gods.’ We all know that is not true,” he said, adding that manuals are not required in health care, but are required in aviation.
However, larger manuals can be difficult to use in an O.R., so Dr. Gaba and others have developed other media to fill the gap.
“It turns out it is not always easy to make cognitive aids easy to use in the heat of the moment. There are usability factors,” Dr. Gaba said. Since the 1990s, anesthesiologists have been developing aids that in recent years have included graphical enhancements to make them even more user-friendly.
“Pocket cards are useful, but when there is more to represent they are not as useful,” he said as he showed cards with tips for dealing with hypoxemia and anaphylaxis. While designed for use during surgery, the aids also can be used for general education, training and pre-case reviews of likely occurrences.
Dr. Gaba and his team at Stanford also have developed a manual that is available for free in a PDF format online. Other institutions, including Brigham & Women’s Hospital, Boston, have done the same, and some commercial publishers also have produced manuals.
“The ultimate rationale is that if cognitive aids save just one life it will be worth it. Jeep would be proud,” Dr. Gaba said of his mentor. “This is not the end… it is just the beginning.”