NASA Model of “Threat and Error” in Pediatric Cardiac Surgery: Patterns of Error Chains Edward Hickey, MD, FRCSC, Eric Pham-Hung, HBSc, Yaroslavna Nosikova,

Slides:

Advertisements

Similar presentations

Repair Type Influences Mode of Pulmonary Vein Stenosis in Total Anomalous Pulmonary Venous Drainage Mauro Lo Rito, MD, Tamadhir Gazzaz, MD, Travis Wilder,

Advertisements

Amy E. Hackmann, MD, Luke M. Wiggins, MD, Glenn P

Association of 24/7 In-House Intensive Care Unit Attending Physician Coverage With Outcomes in Children Undergoing Heart Operations Punkaj Gupta, MBBS,

Clinical Outcomes in Patients With Prolonged Intensive Care Unit Length of Stay After Cardiac Surgical Procedures Ansar Hassan, MD, PhD, Curtis Anderson,

Amit Iyengar, Christopher N. Scipione, MD, Parth Sheth, Richard G

The First Cardiac Operation Using Cardiopulmonary Bypass

Late Vascular Complications After Extracorporeal Membrane Oxygenation Support Daniel Zimpfer, MD, Birgit Heinisch, MD, Martin Czerny, MD, Thomas Hoelzenbein,

Cerebral Oxygen Saturation Does Not Normalize Until After Stage 2 Single Ventricle Palliation Kathleen N. Fenton, MD, Katherine Lessman, BS, Kimberly.

Risk-Adjusted Prolonged Length of Stay as an Alternative Outcome Measure for Pediatric Congenital Cardiac Surgery Ming Liu, MS, MA, Charlotte M. Druschel,

Predicted Risk of Mortality, Transfusion, and Postoperative Outcomes in Isolated Primary Valve Operations W. Brent Keeling, MD, Jose Binongo, PhD, Eric.

Outcome After Rewarming From Accidental Hypothermia by Use of Extracorporeal Circulation Øyvind Sverre Svendsen, MD, PhD, Ketil Grong, MD, PhD, Knut.

Extracorporeal Membrane Oxygenation in Primary Graft Failure After Heart Transplantation Silvana F. Marasco, FRACS, Matthew Vale, PhD, Vince Pellegrino,

Philip J Wolfson, MD The Annals of Thoracic Surgery

Influence of Perioperative Hemodynamics on Spinal Cord Ischemia in Thoracoabdominal Aortic Repair Yujiro Kawanishi, MD, Kenji Okada, MD, Masamichi Matsumori,

The Annals of Thoracic Surgery

Randomized Comparison Between Normothermic and Hypothermic Cardiopulmonary Bypass in Pediatric Open-Heart Surgery Massimo Caputo, MD, Simon Bays, Chris.

Initial Experience With Hybrid Palliation for Neonates With Single-Ventricle Physiology Christopher A. Caldarone, MD, Lee Benson, MD, Helen Holtby, MD,

Successful Bridge Through Transplantation With Berlin Heart Ventricular Assist Device in a Child With Failing Fontan David M. Hoganson, MD, Umar S. Boston,

Total Arch Replacement Under Normothermic Beating Heart Surgery

Michael L. Bailey, MBBS, Sven M. Richter, MD, Daniel V

Hypertrophic Cardiomyopathy in Childhood: Disease Natural History, Impact of Obstruction, and Its Influence on Survival Edward J. Hickey, MD, Brian W.

Leukocyte depletion during cardiac operation: a new approach through the venous bypass circuit Y.John Gu, MD, PhD, A.J de Vries, MD, Paulien Vos, Piet.

Outcomes of Different Surgical Strategies in the Treatment of Neonates with Aortic Coarctation and Associated Ventricular Septal Defects Bahaaldin Alsoufi,

Bahaaldin Alsoufi, MD, Sally Cai, PhD, Glen S

Susanne Lison, MD, Michael Spannagl, MD, PhD, Wulf Dietrich, MD, PhD

Outcomes of Intraoperative Venoarterial Extracorporeal Membrane Oxygenation Versus Cardiopulmonary Bypass During Lung Transplantation Christian A. Bermudez,

Aggressive Patch Augmentation May Reduce Growth Potential of Hypoplastic Branch Pulmonary Arteries After Tetralogy of Fallot Repair Travis J. Wilder,

Tomoaki Murakami, MD, PhD, Atsuhito Takeda, MD, PhD

James D. St. Louis, MD The Annals of Thoracic Surgery

Outcomes Using a Conservative Versus Liberal Red Blood Cell Transfusion Strategy in Infants Requiring Cardiac Operation Jill M. Cholette, MD, Michael.

Survival outcomes after rescue extracorporeal cardiopulmonary resuscitation in pediatric patients with refractory cardiac arrest Bahaaldin Alsoufi, MD,

Use of Amiodarone After Major Lung Resection

Surgical Dilemmas: Diagnosis and Treatment of Atrial Plasmacytoma

Comparative Effects of Ventricular Assist Device and Extracorporeal Membrane Oxygenation on Renal Function in Pediatric Heart Failure Parthak Prodhan,

Is Restrictive Atrial Septal Defect a Risk in Partial Anomalous Pulmonary Venous Drainage Repair? Jiaquan Zhu, MD, PhD, Yasuhiro Kotani, MD, PhD, Devin.

Disruption of the ventricular myocardial force-frequency relationship after cardiac surgery in children: Noninvasive assessment by means of tissue Doppler.

Lung Function and ECMO After Lung Transplantation

Michiaki Imamura, MD, PhD, Amy M

Terry Shih, MD, Justin B. Dimick, MD, MPH

Clinical Outcomes, Program Evolution, and Pulmonary Artery Growth in Single Ventricle Palliation Using Hybrid and Norwood Palliative Strategies Osami.

Postoperative Extracorporeal Membrane Oxygenation Support for Acute Type A Aortic Dissection Ting-Wei Lin, MD, MS, Meng-Ta Tsai, MD, Yu-Ning Hu, MD,

Benjamin C. Sun, MD, Timothy A. Dickinson, CCP, Eric A

Russel Hirsch, Catherine L. Dent, Mary K. Wood, Charles B

Michael J. Wolf, MD, Kirk R. Kanter, MD, Paul M. Kirshbom, MD, Brian E

Lucas W. Thornblade, MD, Aaron M. Cheng, MD, Douglas E

Bradford B. Smith, MD, Matthew A

Completely Thrombosed Tricuspid Pouch Mimicking a Cardiac Tumor

The Impact of 22q11.2 Deletion Syndrome on Surgical Repair Outcomes of Conotruncal Cardiac Anomalies Bahaaldin Alsoufi, MD, Courtney McCracken, PhD,

Preoperative Venoarterial Extracorporeal Membrane Oxygenation Slashes Risk Score in Advanced Structural Heart Disease A. Claire Watkins, MD, Nathan L.

Sequential Design for Clinical Trials Evaluating a Prosthetic Heart Valve Cody Hamilton, PhD, Michael Lu, PhD, Steven Lewis, PhD, William Anderson, PhD

Very Prolonged Stay in the Intensive Care Unit After Cardiac Operations: Early Results and Late Survival Shuli Silberman, MD, Daniel Bitran, MD, Daniel.

Paul Urbanski, MD, PhD The Annals of Thoracic Surgery

Prolonged Intensive Care Unit Stay in Cardiac Surgery: Risk Factors and Long-Term- Survival Ortrud Vargas Hein, MD, Jürgen Birnbaum, MD, Klaus Wernecke,

High-Risk Mitral Valve Surgery: Perioperative Hemodynamic Optimization with Nesiritide (BNP) Sacha P. Salzberg, MD, Farzan Filsoufi, MD, Anelechi Anyanwu,

Pulmonary hypertension is associated with worse early and late outcomes after aortic valve replacement: Implications for transcatheter aortic valve replacement

A Target for Perioperative Blood Pressure During Cardiac Operations

Pulmonary Embolectomy for Acute Massive Pulmonary Embolism

Prospective Validation of a Novel Vasoactive-Ventilation-Renal Score as a Predictor of Outcomes After Pediatric Cardiac Surgery Kyle G. Miletic, MD,

Michael J. Ewing, MS, Philip D. Houck, MD, Glen B. Drake, MD, Kenton J

Use of Ventricular Assist Devices in Children Across the United States: Analysis of 7.5 Million Pediatric Hospitalizations David L.S. Morales, MD, Farhan.

Successful use of argatroban as a heparin substitute during cardiopulmonary bypass: heparin-induced thrombocytopenia in a high-risk cardiac surgical patient

Dumbor L. Ngaage, MD, FRCS (C-Th), Michael E. Cowen, FRCS

Late Consequences of a Much Earlier Decision

The Impact of New Technology on Cardiothoracic Surgical Practice

Reduced Cytokines Release and Myocardial Damage in Coronary Artery Bypass Patients Due to L-Arginine Cardioplegia Supplementation Luisa Colagrande, MD,

Slide Tracheoplasty in Infants and Children: Risk Factors for Prolonged Postoperative Ventilatory Support Peter B. Manning, MD, Michael J. Rutter, MD,

John R. Handy, MD, HonD, Kelly Denniston, RHIT, Gary L

Karl A. Bocchieri, BS, CCP, S. Jacob Scheinerman, MD, L

Short Operation Time: An Important Element to Reduce Operative Invasiveness in Pediatric Cardiac Surgery Makoto Ando, MD, Yukihiro Takahashi, MD, Toshio.

Harvey Edward Garrett, MD, Bradley A. Wolf, MD

Presentation transcript:

NASA Model of “Threat and Error” in Pediatric Cardiac Surgery: Patterns of Error Chains Edward Hickey, MD, FRCSC, Eric Pham-Hung, HBSc, Yaroslavna Nosikova, JD, MASc, Fredrik Halvorsen, MD, PhD, Michael Gritti, HBSc, Steven Schwartz, MD, FRCPC, Christopher A. Caldarone, MD, FRCSC, Glen Van Arsdell, MD, FRCSC The Annals of Thoracic Surgery Volume 103, Issue 4, Pages 1300-1307 (April 2017) DOI: 10.1016/j.athoracsur.2016.08.075 Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Flight plan infographic depicting a child’s inpatient perioperative journey. Children are tracked from the point of admission. Risk is the y-axis, and time is the x-axis. Depiction of risk is figurative and not quantitative. Various threats (T), errors (E), and unintended patient states (U) are tracked on the graphs, and linked together if related. Permanent outcomes (complications persisting beyond discharge) and deaths are also documented. (CPB = cardiopulmonary bypass duration; CVL = central venous line; ECMO = extracorporeal membrane oxygenator; ICU = intensive care unit; RVSP = right ventricular systolic pressure; TEE = trans-esophageal echocardiogram; VSD = ventricular septal defect; XC = aortic cross clamp duration.) The Annals of Thoracic Surgery 2017 103, 1300-1307DOI: (10.1016/j.athoracsur.2016.08.075) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Threat-and-error model proposed by Helmreich [10, 13] and used by the Federal Aviation Administration [9]. Immediate threats (T) are factors outside the control of the cockpit crew (threats come at the crew) and increase the risk of an error (E) being made (errors come from the crew). Errors may be recognized and mitigated, but a consequential error leads to an unintended state (U). Unintended states may be benign if well managed, but are themselves risk factors for additional errors or unintended states. This chain of error or unintended state leads to progressive loss of safety margins and is a prelude to a catastrophic outcome. The Annals of Thoracic Surgery 2017 103, 1300-1307DOI: (10.1016/j.athoracsur.2016.08.075) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Schematic flight plan infographic illustrating the expected deescalation in risk (black line). Failed deescalation in risk (dashed line) is an aberration in this expected sequential reduction in risk level. (E = error; ICU = intensive care unit; OR = operating room; T = threat; U = unintended state.) The Annals of Thoracic Surgery 2017 103, 1300-1307DOI: (10.1016/j.athoracsur.2016.08.075) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 (A) Number of amplifying errors influencing chains of error or unintended clinical state and (B) error category of amplifying errors. The Annals of Thoracic Surgery 2017 103, 1300-1307DOI: (10.1016/j.athoracsur.2016.08.075) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions