Barach P, Basha E, Bogner A, Almad A, Galvan C, Duncan R, Mohr J; AcademyHealth. Meeting (2005 : Boston, Mass.).
Abstr AcademyHealth Meet. 2005; 22: abstract no. 3867.
University Of Miami, Department of Anaesthesia, , Miami, FL Tel. Fax
RESEARCH OBJECTIVE: Pediatric cardiac surgery PCS is a specialty with low error tolerance and encompasses many complex procedures that are dependent upon a sophisticated organizational structure, coordinated efforts of multiple individuals working as a team, and high levels of cognitive and technical performance. Little is known about the interaction between human factors, intraoperative events, and outcomes. We hypothesized that patterns of adverse events occur during PCS and that they may be associated with adverse outcomes. STUDY DESIGN: Prospective observations of PCS procedures in children ranging in age from neonates to 15 year old. The observations began from inception of anesthesia to hand-off to the Intensive Care Unit team by 2 observers trained in PCS techniques and human factors methods. Observations from each case were transcribed and independently analyzed. Events were extracted and coded into compensated or non-compensated major or minor events. Based on NIH definitions, adverse events were defined as unintended incidents in care that may result in adverse outcomes or may require additional care efforts to prevent adverse outcome. Depending on the outcome, they were described as compensated,no adverse outcome or uncompensated. Case complexity was calculated using the AristotleR scoring system. Number and types of events, types of compensatory mechanism or lack thereof, and periods during which events occurred were statistically correlated with case complexity (coded as above and below median complexity) and outcomes (coded as uncomplicated hospital stay, mild morbidity, major morbidity or death)by Chi-square analysis. POPULATION STUDIED: Pediatric Cardiac Surgery teams at two academic health centers, which included surgeons, nurses, perfusionists, anesthesiologists, and technicians. PRINCIPAL FINDINGS: Between 9/1/03 and 9/30/04, 82, 24 percent of a total of 345 cases were observed. The study group mean age was 499 days, range 1-575, the mortality was 4.8%, and the mean complexity 12.1 Range 5-24.5. An average of 1.1 major events, range 0-6 occurred per case. The most common type of event was in the cardiovascular category, 17 percent of all major events, followed by airway/pulmonary, 14 percent, while most events occurred during the post-bypass period, 46 percent. Cognitive compensation was the most common defense mechanism, 38 percent. There were 2 uncompensated major events, arrhythmias leading to ECMO, carotid laceration during line placement resulting in hemorrhage. An average of 13.6 minor events, range 2-35, occurred per case. The most common type of minor event was communication failures, 26 percent. The number of major events/case correlated with adverse outcomes, p<0.05, and with case complexity, p<0.01. CONCLUSIONS: We demonstrated that the number of major events that occur during PCS increases with case complexity and impacts outcome. Team cognitive compensation and not primary prevention was the prevalent system practice. Team training and systems management should be improved. In addition, greater emphasis should be placed on preventive measures. IMPLICATIONS FOR POLICY, DELIVERY OR PRACTICE: The results of this work will be used to direct research on educational and systems interventions to improve team training and patient safety in the OR.
Publication Types:
Keywords:
- Anesthesia
- Child
- Forms and Records Control
- Hospitals
- Humans
- Infant, Newborn
- Intensive Care Units
- Longitudinal Studies
- methods
- therapy
- hsrmtgs
UI: 103623330
From Meeting Abstracts