Thomas Chidester

Clinical error management.

The operating room is a complex environment in which even seemingly insignificant errors can have potentially life-threatening consequences. Ad hoc interprofessional teams with varying levels of training care for patients with multiple comorbidities while they are subjected to a range of physiologic stresses and surgical insults. Patient care in the operating room is a dynamic interaction that requires cooperation among team members and reliance upon sophisticated technology. All members must manage large quantities of rapidly changing information and, ideally, share these data with the rest of the team in an explicit, timely, and contextualized manner. It is, therefore, not surprising that the operating room is home to a large number of adverse events. Schimpff has identified 6 characteristics unique to the perioperative environment that predispose to an error. First, he describes the operating room as a “high-velocity” environment, and as hospitals increasingly rely on surgical volume as a mainstay of economic enterprise, production pressure may increase the likelihood that an error can occur. Second, the patient is usually asleep or sedated and, therefore, cannot be an advocate for his or her own safety (eg, by warning of a drug allergy or by complaining about a pressure point). Third, although there are multiple people working together in the operating room, they rarely function as a true team: each person shares a workspace and overlapping goals, but each has his or her distinct role and works independently. Fourth, in contrast to other safety cultures,

Threat and error management for anesthesiologists: a predictive risk taxonomy

Purpose of review Patient care in the operating room is a dynamic interaction that requires cooperation among team members and reliance upon sophisticated technology. Most human factors research in medicine has been focused on analyzing errors and implementing system-wide changes to prevent them from recurring. We describe a set of techniques that has been used successfully by the aviation industry to analyze errors and adverse events and explain how these techniques can be applied to patient care. Recent findings Threat and error management (TEM) describes adverse events in terms of risks or challenges that are present in an operational environment (threats) and the actions of specific personnel that potentiate or exacerbate those threats (errors). TEM is a technique widely used in aviation, and can be adapted for the use in a medical setting to predict high-risk situations and prevent errors in the perioperative period. A threat taxonomy is a novel way of classifying and predicting the hazards that can occur in the operating room. TEM can be used to identify error-producing situations, analyze adverse events, and design training scenarios. Summary TEM offers a multifaceted strategy for identifying hazards, reducing errors, and training physicians. A threat taxonomy may improve analysis of critical events with subsequent development of specific interventions, and may also serve as a framework for training programs in risk mitigation.

New genetic technology may help pilots, aviation employees, and color vision researchers

Color vision research is not new for the Federal Aviation Administration (FAA); the Civil Aerospace Medical Institute has been conducting color vision research and publishing the results since 1967 ( 3 ). The FAA originally initiated color vision research because of the emerging use of color coding in the airport environment and the FAA has continued a line of color vision research because of the increasing use of color coding resulting from changing technology inside the cockpit, on air traffic control displays, and in the airport environment. Color can be used to convey meaning without supplemental signage such as the ubiquitous traffic signal that alerts drivers to proceed with caution via a yellow flashing light or to stop via a red flashing light. However, that meaning is only conveyed if the driver can distinguish between the yellow and the red colors. Approximately 8 to 10% of the male population ( 5 ) has a congenital color vision deficiency and, depending upon the type and severity of that deficiency, that task of interpreting the meaning of color coding may be difficult or impossible. Consequently, the FAA has long maintained a color vision standard for aero-medical screening to ensure that pilots and air traffic controllers can perform safety-related tasks without adverse consequences. Throughout the past few years, the FAA has explored a variety of color vision tests, searching for a valid screening test that has high sensitivity and specificity, meaning the ability to detect the presence or absence of the deficiency, respectively. Basically, color vision tests can be categorized as diagnostic, screening, or occupational tests. Diagnostic tests are designed to specifically diagnose the type and degree of deficiency, the screening tests focus on differentiating between normal or deficient color vision, and the occupational tests seek to separate those capable versus incapable of certain tasks such as identifying colors of wires or lights (e.g., the Farnsworth Lantern test that was developed to assess the ability of potential Navy signalmen for identifying red, green, and white lights). A few tests have been developed for the purpose of precisely diagnosing and classifying color vision; however, when color vision test scores are compared to performance on occupational tasks such as identifying or discriminating colors used in signal lights, precision approach path indicator (PAPI) lights, colored navigation lights, color coded map reading tasks, color coded air traffic control displays, and cockpit displays, a specific cut-point on those selection tests has not been found that can fully separate those who can from those who cannot accurately perform the color-coded pilot or air traffic control tasks. Some tests, including new computerized instruments, have been designed to differentiate defects involving the long wavelength sensitive cones (protan-type), middle wavelength sensitive cones (deutan-type), and short wavelength sensitive cones (tritan-type). Congenital protan and deutan deficiencies are, collectively, extremely common, affecting 1 in 12 men and 1 in 230 women; however, recent evidence indicates that tritan defects are virtually never present at birth (e.g., congenital) and the inherited forms involve S cone photoreceptor degeneration that develops later in life with the exact onset depending upon the specific mutation ( 1, 4 ). Thus, the exact frequency of inherited tritan defects is uncertain; however, it is probably less than 1 in 500. In part, because the underlying pathophysiology has not been well understood, few tests have been available that are capable of detecting tritan deficiencies. In the past, those tests included the single Farnsworth F2 pseudoisochromatic plate (PIP), the Moreland anomaloscope, the Hardy, Rand, Rittler PIP test, and, most recently, the Oculus anomaloscope. Consequently, the occupational color vision tests used by most agencies only screen for the most common (protan and deutan) types of defects. The newly developed computerized color vision tests, including the Colour Assessment and Diagnostic Test, the Cambridge Colour Test, the Cone Contrast Test, and the Computerized Color Vision Test, are all designed to detect tritan defects. However, tritan weaknesses have been noted in several of the FAA ‘ s recent studies in much higher than the traditionally expected numbers and diagnostic agreement is low among those tests when tritan deficiencies are involved. In the past, the FAA and other regulatory organizations have not, or have rarely, required tritan color vision screening in their occupational screening because of the following three factors: the rarity of the congenital defect, the unknown number of individuals affected by acquired deficiencies, and the lack of effective, reliable, valid, and affordable equipment with which to diagnose the deficiency.