The Wolf Is Crying in the Operating Room

Schmid, Félix; Goepfert, Matthias S.; Kuhnt, Daniela; Eichhorn, Volker; Diedrichs, Stefan; Reichenspurner, Hermann; Goetz, Alwin E.; Reuter, Daniel A.

doi:10.1213/ane.0b013e3181fcc504

Cited by 101 publications

(35 citation statements)

References 13 publications

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“…Also this alternative analytical pathway would rest on an extensive research base of how to design and understand joint cognitive healthcare working environments (Cook and Woods, 1996;Woods, 1995;Schmid et al, 2011;Raymer et al, 2012;Raymer and Bergström, 2013;Klein et al, 2004;Hollnagel and Woods, 2005).…”

Section: Discussionmentioning

confidence: 99%

One event, three investigations: The reproduction of a safety norm

2017

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a b s t r a c tFollowing an adverse event in a Swedish university hospital in 2010, three separate investigations seeking causal factors were conducted. We here review each of the analyses to see whether they together generate the kind of epistemological pluralism that could contribute to a systemic understanding of, and learning from, the event. Our content analysis shows that, while using vastly different amounts of time and resources, all three investigations make the same analytical choice to construct the causal factors as a deviation from norm in the event's immediate temporal and spatial proximity. We recognise that this both represents a strong discourse in the community analysing adverse events and seems to fulfil certain psychological purposes. Furthermore, we suggest that thorough analysis of adverse events in healthcare need to include aspects of system interaction from the micro to the macro, cognitive work configuration and design, as well as variability as a resource to harness rather than a threat to limit and control.

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Section: Discussionmentioning

confidence: 99%

One event, three investigations: The reproduction of a safety norm

2017

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“…First, false alarms vastly outnumber real events because disconnection of sensors (“asystole”), blood draws, and electrocautery are more common than cardiac arrest in most ORs 113,114. Monitoring devices can also fail from heavy use.…”

Section: Partmentioning

confidence: 99%

Anesthesia advanced circulatory life support

Moitra

Gabrielli

Maccioli³

et al. 2012

Can J Anesth/J Can Anesth

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PurposeThe constellation of advanced cardiac life support (ACLS) events, such as gas embolism, local anesthetic overdose, and spinal bradycardia, in the perioperative setting differs from events in the pre-hospital arena. As a result, modification of traditional ACLS protocols allows for more specific etiology-based resuscitation.Principal findingsPerioperative arrests are both uncommon and heterogeneous and have not been described or studied to the same extent as cardiac arrest in the community. These crises are usually witnessed, frequently anticipated, and involve a rescuer physician with knowledge of the patient’s comorbidities and coexisting anesthetic or surgically related pathophysiology. When the health care provider identifies the probable cause of arrest, the practitioner has the ability to initiate medical management rapidly.ConclusionsRecommendations for management must be predicated on expert opinion and physiological understanding rather than on the standards currently being used in the generation of ACLS protocols in the community. Adapting ACLS algorithms and considering the differential diagnoses of these perioperative events may prevent cardiac arrest.

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“…Schmid et al [19] studied perioperative alarms in a highly complex surgical setting and included 25 patients undergoing elective cardiac surgery with extracorporeal circulation. All patient monitor and anesthesia workstation alarms were digitally recorded.…”

Section: Alarm-related Problemsmentioning

confidence: 99%

“…Schmid et al found different characteristic patterns and density of alarms in 4 different intraoperative phases (beginning of surgery, start of extracorporeal circulation [ECC], end of ECC, end of surgery) [19]. …”

Section: Technical Approaches For False Alarm Reductionmentioning

confidence: 99%

“…Görges et al [38] showed in an ICU setting and Schmid et al [19] in an intraoperative setting that a great number of false alarms are caused by only mild threshold violations of short duration. In an offline validation, Görges et al showed that the implementation of a 14-second delay reduced false alarms by 50%; a 19-second delay reduced false alarms by 67%.…”

Section: Technical Approaches For False Alarm Reductionmentioning

confidence: 99%

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