The trojan horse of the operating room: Alarms and the noise of anesthesia

Misadventures in Health Care: Inside Stories

Volumn , Issue , 2003, Pages 105-126

  Jacob Seagull, F ^a   Sanderson, Penelope M ^b  

^a UNIVERSITY OF MARYLAND SCHOOL OF MEDICINE   (United States)

^b UNIVERSITY OF QUEENSLAND   (Australia)

Author keywords

[No Author keywords available]

Indexed keywords

EID: 0346289868     PISSN: None     EISSN: None     Source Type: Book    
DOI: 10.4324/9781410609038-15     Document Type: Chapter

References (78)

1. Baskett, P. J. F., Dow, A., Nolan, J., & Maull, K. (1994). Practical procedures in anesthesia and critical care. London: Mosby.
2. Ben-Barak, S., Inselbuch, M., Hyams, G., Straucher, Z., Michaelson, M., Gopher, D., Tal-Or, E., & Klein, Y. (1999, June 15-17). Teamwork in a complex system: An analysis of a hospital shock-trauma unit. Proceedings of the International Conference on TQM and Human Factors- toward successful integration. Linkoping, Sweden.
3. Bliss, J. P., Gilson, R. D., & Deaton, J. E. (1995). Human probability matching behavior in response to alarms of varying reliability. Ergonomics, 38, 2300-2313.
4. Block, F. E. (1988). Evaluation of users’ abilities to recognize musical alarm tones. Journal of Clinical Monitoring, 8, 285.
5. Blom, J. A. (1988). Real-time expert systems in patient monitoring. Journal of Clinical Monitoring, 4, 130-131.
6. Bogner, M. S. (1994). Human error in medicine. Hillsdale, NJ: Lawrence Erlbaum Associates.
7. Bogner, M. S. (2000, November 20-24). Stretching the search for the “why” of error: The systems approach. Proceedings of the Fifth Australian Aviation Psychology Symposium. Manly, Australia.
8. Breznitz, S. (1984). Cry wolf: The psychology of false alarms. Hillsdale, NJ: Lawrence Erlbaum Associates.
9. Cook, R. I., & Woods, D. D. (1996). Adapting to new technology in the operating room. Human Factors, 38, 593-613.
10. Cropp, A. J., & Woods, L. A. (1994). Name that tone: The proliferation of alarms in the intensive care unit. Chest, 105(4), 1217-1220.
11. Drui, A. B., Behm, R. J., & Martin, W. E. (1973). Predesign investigation of the anesthesia operational environment. Anesthesia and Analgesia, 52, 584-91.
12. Harper, B. D., Jaberi, M., Mackenzie, C. F., & LOTAS. (1996). Increasing efficiency in the Trauma Resuscitation Anesthesia workspace. Anesthesiology, 85(3A) [Abstract], A378.
13. Hay, D., & Oken, D. (1972). The psychological stresses of intensive care nursing. Psychosomatic Medicine, 34, 109-118.
14. Helmreich, R. L., & Schaefer, H. (1994). Team performance in the operating room. In M. S. Bogner (Ed.), Human error in medicine (pp. 225-253). Hillsdale, NJ: Lawrence Erlbaum Associates.
15. Hyman, W. A., & Drinker, P. A. (1983). Design of medical device alarm systems. Medical Instrumentation, 17, 103-106.
16. Joint Commission on Accreditation of Healthcare Organizations (2000, February 4). Operative and post-operative complications: Lessons for the future. Sentinel Event Alert, 12. Available online: http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/print/sea_12.htm
17. Kennedy, P. J., Fiengold, F., Weiner, E. L., & Hosek, R. S. (1976). Analysis of task and human factors in anesthesia for coronary artery bypass. Anesthesia and Analgesia, 55, 374-377.
18. Kestin, I. G., Miller, B. T., & Lockhart, C. H. (1988). Auditory alarms during anesthesia monitoring. Anesthesiology, 69, 106.
19. Loeb, G. J., Brunner, J. X., Westenskow, D. R., Feldman, B., & Pace, N. L. (1989). The Utah anesthesia workstation. Anesthesiology, 70, 999-1007.
20. Loeb, R. G., Jones, B. R., Leonard, R. A., & Behrman, K. (1992). Recognition accuracy of current operating room alarms. Anesthesia and Analgesia, 74, 499-505.
21. Mackenzie, C. F., Martin, P., Xiao, Y., & the LOTAS Group (1996). Video analysis of prolonged uncorrected esophageal intubation. Anesthesiology, 84(6), 1394-1403.
22. McIntyre, J. W. R. (1982). Man-machine interface: The position of the anesthetic machine in the operating room. Canadian Anesthesia Society Journal, 29, 74-78.
23. McIntyre, J. W. R. (1985). Ergonomics: Anaesthetists’ use of auditory alarms in the operating room. International Journal of Clinical Monitoring and Computing, 2, 47-55.
24. Meredith, C., & Edworthy, J. (1995). Are there too many alarms in the intensive care unit? An overview of the problems. Journal of Advanced Nursing, 21, 15-20.
25. Momtahan, K. L., Hetu, R., & Tansley, B. W. (1993). Audibility and identification of auditory alarms in operating rooms and an intensive care unit. Ergonomics, 36, 1159-1176.
26. Mylrea, K. C., Orr, J. A., & Westenskow, D. R. (1993). Integration of monitoring for intelligent alarms in anesthesia: Neural networks-can they help? Journal of Clinical Monitoring, 9, 31-37.
27. Navabi, M. J., Mylrea, K. C., & Watt, R. C. (1989). Detection of false alarms using an integrated anesthesia monitor. IEEE Engineering Medical Biological Society 11th Annual International Conference, 11, 1774-1775.
28. Orr, J. A., & Westenskow, D. R. (1994). A breathing circuit alarm system based on neural networks. Journal of Clinical Monitoring, 10, 101-109.
29. Seagull, F. J., & Sanderson, P. M. (2001). Anesthesia alarms in surgical context: An observational study. Human Factors, 43(1), 66-78.
30. Senders, J. W., & Moray, N. P. (1991). Human error: Cause, prediction, and reduction. Hillsdale, NJ: Lawrence Erlbaum Associates.
31. Stanton, N. A. (1994). Alarm initiated activities. In N. A. Stanton (Ed.), Human factors in alarm design (pp. 93-117). London: Taylor & Francis.
32. Topf, M., & Dillon, E. (1988): Noise-induced stress as a predictor of burnout in critical care nurses. Heart Lung, 17, 567-74.
33. Weinger, M. B. (1995). Cardiovascular reactivity among surgeons: Not music to everyone’s ears. Journal of the American Medical Association, 273, 1090-1091.
34. Weinger, M. B., & Englund, C. E. (1990). Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating room environment. Anesthesiology, 73, 995-1021.
35. Woods, D. D. (1995). The alarm problem and directed attention in dynamic fault management. Ergonomics, 38, 2371-2394.
36. Xiao, Y., Hunter, W. A., Mackenzie, C. F., Jefferies, N. J., Horst, R., & the LOTAS Group (1996). Task complexity in emergency medical care and its implications for team coordination. Human Factors, 38(4), 636-645.
37. Xiao, Y., Mackenzie, C. F., Jaberi, M., Harper, B., & the LOTAS Group (1996). Alarms:Silenced, ignored, and missed. Anesthesiology, 73, 995-1021.
38. Xiao, Y., Mackenzie, C. F., Patey, R., & the LOTAS Group (1998). Team coordination and breakdowns in a real-life stressful environment. Proceedings of the Human Factors and Ergonomics 42nd Annual Meeting, 1999 (pp. 186-190). Santa Monica, CA: Human Factors and Ergonomics Society.
39. Xiao, Y., & Seagull, F. J. (1999). An analysis of problems with auditory alarms: Defining the role of alarms in process monitoring tasks. Proceedings of the Human Factors and Ergonomics Society 43rd Annual Meeting, 1999 (pp. 256-260). Santa Monica, CA: Human Factors and Ergonomics Society.
40. Baskett, P. J. F., Dow, A., Nolan, J., & Maull, K. (1994). Practical procedures in anesthesia and critical care. London: Mosby.
41. Ben-Barak, S., Inselbuch, M., Hyams, G., Straucher, Z., Michaelson, M., Gopher, D., Tal-Or, E., & Klein, Y. (1999, June 15-17). Teamwork in a complex system: An analysis of a hospital shock-trauma unit. Proceedings of the International Conference on TQM and Human Factors- toward successful integration. Linkoping, Sweden.
42. Bliss, J. P., Gilson, R. D., & Deaton, J. E. (1995). Human probability matching behavior in response to alarms of varying reliability. Ergonomics, 38, 2300-2313.
43. Block, F. E. (1988). Evaluation of users’ abilities to recognize musical alarm tones. Journal of Clinical Monitoring, 8, 285.
44. Blom, J. A. (1988). Real-time expert systems in patient monitoring. Journal of Clinical Monitoring, 4, 130-131.
45. Bogner, M. S. (1994). Human error in medicine. Hillsdale, NJ: Lawrence Erlbaum Associates.
46. Bogner, M. S. (2000, November 20-24). Stretching the search for the “why” of error: The systems approach. Proceedings of the Fifth Australian Aviation Psychology Symposium. Manly, Australia.
47. Breznitz, S. (1984). Cry wolf: The psychology of false alarms. Hillsdale, NJ: Lawrence Erlbaum Associates.
48. Cook, R. I., & Woods, D. D. (1996). Adapting to new technology in the operating room. Human Factors, 38, 593-613.
49. Cropp, A. J., & Woods, L. A. (1994). Name that tone: The proliferation of alarms in the intensive care unit. Chest, 105(4), 1217-1220.
50. Drui, A. B., Behm, R. J., & Martin, W. E. (1973). Predesign investigation of the anesthesia operational environment. Anesthesia and Analgesia, 52, 584-91.
51. Harper, B. D., Jaberi, M., Mackenzie, C. F., & LOTAS. (1996). Increasing efficiency in the Trauma Resuscitation Anesthesia workspace. Anesthesiology, 85(3A) [Abstract], A378.
52. Hay, D., & Oken, D. (1972). The psychological stresses of intensive care nursing. Psychosomatic Medicine, 34, 109-118.
53. Helmreich, R. L., & Schaefer, H. (1994). Team performance in the operating room. In M. S. Bogner (Ed.), Human error in medicine (pp. 225-253). Hillsdale, NJ: Lawrence Erlbaum Associates.
54. Hyman, W. A., & Drinker, P. A. (1983). Design of medical device alarm systems. Medical Instrumentation, 17, 103-106.
55. Joint Commission on Accreditation of Healthcare Organizations (2000, February 4). Operative and post-operative complications: Lessons for the future. Sentinel Event Alert, 12. Available online: http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/print/sea_12.htm
56. Kennedy, P. J., Fiengold, F., Weiner, E. L., & Hosek, R. S. (1976). Analysis of task and human factors in anesthesia for coronary artery bypass. Anesthesia and Analgesia, 55, 374-377.
57. Kestin, I. G., Miller, B. T., & Lockhart, C. H. (1988). Auditory alarms during anesthesia monitoring. Anesthesiology, 69, 106.
58. Loeb, G. J., Brunner, J. X., Westenskow, D. R., Feldman, B., & Pace, N. L. (1989). The Utah anesthesia workstation. Anesthesiology, 70, 999-1007.
59. Loeb, R. G., Jones, B. R., Leonard, R. A., & Behrman, K. (1992). Recognition accuracy of current operating room alarms. Anesthesia and Analgesia, 74, 499-505.
60. Mackenzie, C. F., Martin, P., Xiao, Y., & the LOTAS Group (1996). Video analysis of prolonged uncorrected esophageal intubation. Anesthesiology, 84(6), 1394-1403.
61. McIntyre, J. W. R. (1982). Man-machine interface: The position of the anesthetic machine in the operating room. Canadian Anesthesia Society Journal, 29, 74-78.
62. McIntyre, J. W. R. (1985). Ergonomics: Anaesthetists’ use of auditory alarms in the operating room. International Journal of Clinical Monitoring and Computing, 2, 47-55.
63. Meredith, C., & Edworthy, J. (1995). Are there too many alarms in the intensive care unit? An overview of the problems. Journal of Advanced Nursing, 21, 15-20.
64. Momtahan, K. L., Hetu, R., & Tansley, B. W. (1993). Audibility and identification of auditory alarms in operating rooms and an intensive care unit. Ergonomics, 36, 1159-1176.
65. Mylrea, K. C., Orr, J. A., & Westenskow, D. R. (1993). Integration of monitoring for intelligent alarms in anesthesia: Neural networks-can they help? Journal of Clinical Monitoring, 9, 31-37.
66. Navabi, M. J., Mylrea, K. C., & Watt, R. C. (1989). Detection of false alarms using an integrated anesthesia monitor. IEEE Engineering Medical Biological Society 11th Annual International Conference, 11, 1774-1775.
67. Orr, J. A., & Westenskow, D. R. (1994). A breathing circuit alarm system based on neural networks. Journal of Clinical Monitoring, 10, 101-109.
68. Seagull, F. J., & Sanderson, P. M. (2001). Anesthesia alarms in surgical context: An observational study. Human Factors, 43(1), 66-78.
69. Senders, J. W., & Moray, N. P. (1991). Human error: Cause, prediction, and reduction. Hillsdale, NJ: Lawrence Erlbaum Associates.
70. Stanton, N. A. (1994). Alarm initiated activities. In N. A. Stanton (Ed.), Human factors in alarm design (pp. 93-117). London: Taylor & Francis.
71. Topf, M., & Dillon, E. (1988): Noise-induced stress as a predictor of burnout in critical care nurses. Heart Lung, 17, 567-74.
72. Weinger, M. B. (1995). Cardiovascular reactivity among surgeons: Not music to everyone’s ears. Journal of the American Medical Association, 273, 1090-1091.
73. Weinger, M. B., & Englund, C. E. (1990). Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating room environment. Anesthesiology, 73, 995-1021.
74. Woods, D. D. (1995). The alarm problem and directed attention in dynamic fault management. Ergonomics, 38, 2371-2394.
75. Xiao, Y., Hunter, W. A., Mackenzie, C. F., Jefferies, N. J., Horst, R., & the LOTAS Group (1996). Task complexity in emergency medical care and its implications for team coordination. Human Factors, 38(4), 636-645.
76. Xiao, Y., Mackenzie, C. F., Jaberi, M., Harper, B., & the LOTAS Group (1996). Alarms:Silenced, ignored, and missed. Anesthesiology, 73, 995-1021.
77. Xiao, Y., Mackenzie, C. F., Patey, R., & the LOTAS Group (1998). Team coordination and breakdowns in a real-life stressful environment. Proceedings of the Human Factors and Ergonomics 42nd Annual Meeting, 1999 (pp. 186-190). Santa Monica, CA: Human Factors and Ergonomics Society.
78. Xiao, Y., & Seagull, F. J. (1999). An analysis of problems with auditory alarms: Defining the role of alarms in process monitoring tasks. Proceedings of the Human Factors and Ergonomics Society 43rd Annual Meeting, 1999 (pp. 256-260). Santa Monica, CA: Human Factors and Ergonomics Society.