Production pressure, medical errors, and the pre-anesthesia checkout

Middle East Journal of Anesthesiology

Volumn 20, Issue 5, 2010, Pages 631-638

  deMaria Jr , Samel ^a   Neustein, Steven M ^a  

^a MOUNT SINAI MEDICAL CENTER   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ANESTHESIOLOGY; CHECKLIST; HUMAN; MEDICAL ERROR; OPERATING ROOM; REVIEW; SAFETY; WORKLOAD;

ANESTHESIOLOGY; CHECKLIST; HUMANS; MEDICAL ERRORS; OPERATING ROOMS; SAFETY; WORKLOAD;

EID: 77956327307     PISSN: 05440440     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Review

References (59)

1. Cooper JB, Newbower RS, Long CD, McPeek B. Preventable anesthesia mishaps-a study of human factors. Anesthesiology 1978;49:399-406.
2. Cooper JB, Newbower RS, Kitz RJ. An analysis of major errors and equipment falures in anesthesia management-considerations for prevention and detection. Anesthesiology 1984;60:34-42.
3. I nstitute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press;2001.
4. Gravenstein JS. How does human error affect safety in anesthesia? Surg Oncol Clin N Am 2000;9(1):81-95.
5. Reason J. Human error: models and management. BMJ 2000;320:768-770.
6. http://www.ahrq.gov/qual/hospsurvey09/ (accessed May 10, 2009)
7. Epsin S, Lingard L, Baker GR, Regeh G. Error management:Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room. Quality and Safety in Health Care 2006;15:165-170.
8. Reason JT, Carthey J, de Leval MR. Diagnosing "vulnerable system syndrome": an essential prerequisite to effective risk management. Qual Health Care 2001;10 (Suppl II):21-5.
9. Epsin S, Lingard L. Time as a catalyst for nurse-surgeon communication. AORN J 2001; 74: 672-82.
10. Beaudouin-Lafon M and Yves G. Fitts' law 50 years later: applications and contributions from human-computer interaction. International Journal of Human-Computer Studies 2004; 61(6): 747-50.
11. Amalberti R. The paradoxes of almost totally safe transportation systems. Saf Sci 2001;37:109-26.
12. Tucker A, Edmondson A. Why hospitals don't learn from failures: organizational and psychological dynamics that inhibit system change. Calif Manage Rev 2003;45:55-72.
13. Gaba DM, Howard S, Jump B. Production pressure in the work environment: California Anesthesiologists' Attitudes and Experiences. Anesthesiology 1994; 81: 488-500.
14. Weissman JS, Rothschild JM, Bendavid E, Sprivulis P, Cook EF, Evans RS, Kaganova Y, Bender M, David-Kasdan J, Haug P, Lloyd J, Selbovitz LG, Murff HJ, Bates DW. Hospital workload and adverse events.Med Care 2007;45(5):448-55.
15. Richardson D. Increase in 10-day mortality associated with ED overcrowding. Med J Aust 2006;184:213-216.
16. Sprivulis P, DaSilva J, Jacobs IG, Frazer AR, Jelinek, GA. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust 2006;184:208-212.
17. Christian CK, Gustafson ML, Roth EM, Sheridan TB, Gandhi TK, Dwyer K, Zinner MJ, Dierks MM. A prospective study of patient safety in the operating room. Surgery. 2006;139(2):159-73.
18. McGowan JE, Truwit JD, Cipriano P, Howell RE, VanBree M, Garson A Jr, Hanks JB. Operating room efficiency and hospital capacity: factors affecting operating room use during maximum hospital census. J Am Coll Surg 2007;204(5):865-71
19. Overdyk FJ, Harvey SC, Fishman RL, Shippey F. Successful strategies for improving operating room efficiency at academic institutions. Anesth Analg 1998;86(4):896-906.
20. Dexter F. Impact on operating room efficiency of reducing turnover times and anesthesia-controlled times. Ann Surg 2007;245(2):336-7.
21. Harders M, Malangoni MA, Weight S, Sidhu T. Improving operating room efficiency through process redesign. Surgery 2006;140(4):509-14.
22. McIntosh C, Dexter F, Epstein RH. The impact of servicespecific staffing, case scheduling, turnovers, and first-case starts on anesthesia group and operating room productivity: a tutorial using data from an Australian hospital. Anesth Analg 2006;103(6):1499-516.
23. Amalberti R, Auroy Y, Berwick D, Barach P. Five system barriers to achieving ultrasafe health care. Ann Intern Med 2005;142:756-64.
24. Kain ZN, Chan KM, Katz JD, Nigam A, Fleisher L, Dolev J, Rosenfeld LE. Anesthesiologists and acute perioperative stress: a cohort study. Anesth Analg 2002;95(1):177-83.
25. Dickson DE. Stress. Anaesthesia 1996; 51: 523-4.
26. Seeley HF. The practice of anesthesia: a stressor for the middleaged? Anaesthesia 1996; 51: 571-4.
27. Simpson LA, Grant L. Sources and magnitude of job stress among physicians. J Behav Med 1991; 14: 27-42.
28. Jackson S. The role of stress in anaesthetists' health and well-being Acta Anaesthesiol Scand 1999; 43: 583-602.
29. Hobbs A, Williamson A. Associations between errors and contributing factors in aircraft maintenance. Hum Factors 2003; 45(2):186-201
30. Perrow C. Normal Accidents. New York, NY. Basic Books, 1984.
31. Lewis RS. Challenger: The Final Voyage. New York, NY. Columbia University Press, 1990.
32. Rasmussen J. Cognitive control and human error mechanisms: New technology and human error. Chichester. J. Wiley & Sons. 1987.
33. Reason J. The contribution of latent human failures to the breakdown of complex systems. Philos Trans R Soc Lond 1990;327:475-84.
34. Brennan TA, Leape LL, Laird NM, Heber Lt, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, and Hiatt HH. Harvard Medical Practice Study I. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I, 1991. Qual Saf Health Care 2004;13:145-51.
35. Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, Etchells E, Ghali WA, Hébert P, Majumdar SR, O'Beirne M, Palacios-Derflingher L, Reid RJ, Sheps S, Tamblyn R. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004;170:1678-86.
36. Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery 1999;126:66-75.
37. Gaba DM, Singer SJ, Sinaiko AD, Bowen JD, Ciavarelli AP. Differences in safety climate between hospital personnel and naval aviators. Human Factors 2003;45:173-85.
38. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ 2000;320:745-9.
39. Frone, MR. Predictors of work injuries among employed adolescents. Journal of Applied Psychology 1998;83:565-76.
40. Zohar D. A group-level model of safety climate: Testing the effct of group climate on microaccidents in manaacturing jobs. Journal of Applied Psychology 2000;85: 587-96.
41. Reason J. Managing the Risks of Organizational Accidents. Aldershot: Ashgate Publishing Limited, 1997.
42. Seki Y. Working condition factors associated with time pressure of nurses in Japanese hospitals. J Occup Health 2008;50(2):181-90.
43. Elfering A, Semmer NK, Grebner S. Work stress and patient safety: observer-rated work stressors as predictors of characteristics of safety-related events reported by young nurses. Ergonomics. 2006;49(5-6):457-69.
44. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 2002;288:1987-93.
45. Matthews G, Davies DR, Westerman SJ, Stammers RB. Human performance: Cognition, stress and individual differences. Hove, UK: Psychology Press, 2000.
46. Hockey GR. Compensitory control in the regulation of human performance under stress and high workload: A cognitive-energetical framework. Biological Psychology 1997;45:73-93.
47. Schonpflug W, Battman W. Handbook of Life Stress, Cognition and Heatlth. New York, NY: Wiley, 1988.
48. Van Hiel A, Mervielde I. The search for complex problem-solving strategies in the presence of stressors. Hum Factors 2007;49(6):1072-82.
49. Croskerry P. The theory and practice of clinical decision-making. Can J Anesth 2005. 52(6): R1-8.
50. Healzer JM, Howard SK, Gaba DM. Attitudes toward production pressure and patient safety: A survey of anesthesia residents. Journal of Clinical Monitoring and Computing 1998; 14:145-6.
51. Freund PR, Posner KL. Sustained increases in productivity with maintenance of quality in an academic anesthesia practice. Anesth Analg 2003;96(4):1104-8.
52. Posner KL, Freund PR. Trends in quality of anesthesia care associated with changing staffing patterns, productivity, and concurrency of case supervision in a teaching hospital. Anesthesiology 1999;91:839-47.
53. Feldman JM, Olympio MA, Martin D, Striker A. New Guidelines Available for Pre-Anesthesia Checkout. Anesthesia Patient Safety Foundation Newsletter 2008; 23(1): 23-25.
54. Cooper JB, Newbower RS, Kitz RJ. An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. Anesthesiology 1984;60:34-42.
55. Anesthesia Apparatus Checkout Recommendations, 1993. Available at: http://www.osha.gov/dts/osta/anestheticgases/index.html#Appendix2. Accessed February 13, 2009.
56. Haynes AB, Weiser TG, Berry WR, et al. Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. NEJM 2009; 360:491-499.
57. Hales BM and Pronovost PJ. The checklist-a tool for error management and performance improvement. J of Crit Care 2006; 21: 231-5.
58. Pani JR, Chariker JH. The psychology of error in relaton to medical practice. Journal of Surgical Oncology 2004; 88: 130-142.
59. Weick KE. The reduction of medical errors through mindful interdependence. In: Rosenthal MM, Sutciffe KM, ed. Medical Error. San Fransisco, CA: Jossey-Bass;2002. 177-199.