The Right Systems, Not ‘The Right Stuff,’ Can Reduce Anesthesia Errors

Incorporating design principles into the anesthesiology workspace is crucial to reducing medication administration errors, according to investigators at Seattle Children’s Hospital and the University of Washington, in Seattle.

Eliot Grigg, MD, assistant professor of anesthesiology and pain medicine at the University of Washington and director of sedation at Seattle Children’s Hospital, likened current thinking about anesthesia delivery to the idea of “the right stuff,” as expressed by author Tom Wolfe in his 1979 book of the same name.

In the book, Wolfe valorized the exceptional qualities of the test pilots imbued with the so-called right stuff at the expense of emphasizing the design qualities of the aircraft that kept those pilots alive.

Similarly, Dr. Grigg, in a presentation titled “Can You Design Your Workspace to Reduce Errors?” at the 2017 meeting of the Society for Pediatric Anesthesia/American Academy of Pediatrics Section on Anesthesiology and Pain Medicine, noted that anesthesiologists operate in an environment of extreme complexity while relying largely on their wits and training, when they could benefit from a thoughtfully designed environment.

“A lot of the morbidity in anesthesia is from the way it’s delivered, more so than inherent problems in the tools and medications that we use.”

Many Opportunities To Fail

With reference to cognitive load theory, which posits that humans have a limited capacity to process information from the environment, Dr. Grigg offered several illustrations demonstrating the high stakes and high level of complexity involved in anesthesia decision making. He emphasized the inherent cognitive limitations of anesthesiologists, no matter how skilled, such as the limited ability to quickly distinguish between objects of varying shapes and colors. He noted that while anesthetic equipment has seen a lot of innovation over the years, the fundamental processes of medication delivery had not.

As a result, he said, the cycle of medication delivery involved an inordinate number of steps, creating too many opportunities for failure.

“When we give medications, there’s no real dose checking; there are no alarms on the entire left side of our workspace—there’s really no way to detect errors. It’s a very simplistic system we have right now in terms of dealing with medication,” he said.

Dr. Grigg described a recent study he led at the University of Washington/Seattle Children’s Hospital in collaboration with colleagues from the Division of Design in the School of Art + Art History + Design and the Children’s Core for Biomedical Statistics at Seattle Children’s Research Institute.

Together they created a system they dubbed the Anesthesia Medication Template (AMT), an intuitive, clean and user-friendly method of organizing the anesthesiology workspace derived from the principles of good design.

“Conceptually it’s very simple. It’s called a shadow board—my bike shop has one for wrenches and things (Figure),” Dr. Grigg said. “But what we did was, we went to some real experts—being in Seattle, we’re just down the road from Boeing. We grabbed some professors who worked on the 787 cockpit and said, ‘Teach us what you know about design, and let’s bring some of that into the operating room [OR].’”

Errors Drop

They found that in the simulated emergencies, the odds of medication dosing errors using the AMT were 0.21 times the odds of medication dosing errors without using the AMT (95% CI, 0.07-0.66). This finding held after controlling for potentially confounding factors, such as the providers’ level of training.

In the second phase, in the year after implementing the AMT, they found that the mean monthly error rate for all reported medication errors that reached patients decreased from 1.24 (95% CI, 0.85-1.79) to 0.65 (95% CI, 0.39-1.09) errors per 1,000 anesthetics, and that the mean monthly rate of swap, preparation, miscalculation and timing errors decreased from 0.97 (95% CI, 0.64-1.48) to 0.35 (95% CI, 0.17-0.70) per 1,000 anesthetics.

In other words, Dr. Grigg said, use of the AMT correlated with drops in the error rates on the order of 80% in simulations, and 50% to 60% in the OR.

Dr. Grigg noted that the study was unable to show a difference in events resulting in patient harm, and imputed that lacuna to their low incidence, which he estimated at around five per year at their institution. Regardless, he and his colleagues concluded that implementing the AMT could be an inexpensive and intuitive way of reducing medication errors in anesthesia.

Ultimately, Dr. Grigg emphasized the idea of “designing the world so that it’s easier to do the right thing.

“For me, that’s been the real lesson in a lot of this, asking ‘How can I make my colleagues more effective?’ rather than ‘How can I prevent something bad from happening?’ and as a result making everything harder to do,” he said.

Dr. Grigg’s presentation was “fantastic,” according to Thomas Chokwe, MD, an anesthesiologist in the Department of Surgery at the University of Nairobi, in Kenya, who said the presentation addressed a fundamental issue in anesthesia.

“It’s a real headache—anesthesia is one of the very few medical specialties where one person makes the diagnosis, fills the prescription, acquires the medication, administers the medication and monitors it,” Dr. Chokwe said. “So you have to put that in somebody’s mind, and make sure it’s digested completely.”