House surgeon teaching 2018 J Albrett Crisis management House surgeon teaching 2018 J Albrett

What is a crisis?

Why do humans makes errors?

The individual human Constructs a world view Adjust information (distort) to fit present assumptions Defend feeling competent at almost any cost!

The team of humans Members tend to go with the majority view Legitimate concerns are frequently withheld Misunderstanding commonly follows ambiguous terminology With increasing pressure information and decisions are made centrally

The organisation Multiple subsystems with unique cultures Surgery Vs Medicine ED Vs the wards Inpatient Vs Outpatient care Competing goals Safer cheaper healthcare Increased productivity

The system Economic pressure Funding incl. Working time limits Public Vs private Mandatory insurance Taxation Working time limits Government regulation Costs of training and professional development

Errors

Person based approach Look for who is at fault when error occurs Look for reasons why they made error Lack of knowledge Lack of attention Lazy, reckless, stupid Moral issue “Name, blame and shame”

System based approach The human condition can not be changed The system can be changed to influence the likelihood of errors occurring.

Stress The flight or flight mechanism narrows thinking, focus on the task at hand to survive… BUT May screen out important information May lose situational awareness Goals become very short-term and medium and long-term consequences are ignored

Problem 1 ED is very busy. There are 31 people waiting to be assessed and six patients need clarking prior to transfer to the medical ward. Your registrar is involved in resus with a 38 year old man being thrombolysed for STEMI. You have been told to see as many patients as possible as fast as you can! The charge nurse is angry and you overhear them say, “…and the house surgeons isn’t one of the good ones!”

Chose one of… A 53 year old man with angina, recently had negative ETT. A lot of risk factors incl Type 2 DM, obesity, smoker, strong FHx A 28 year old with CF who has a productive cough, fever and mild SOB. 4L/min O2 A 66 year old with probable infectious exacerbation of COPD. Ex smoker, on home oxygen A 86 year old who failed an elderly at risk assessment in ED with new confusion A 73 year old man with left calf pain, chest pain and SOB.

What other information could you obtain quickly? Who could help you? What are your obstacles? What could go wrong?

Problem 2 You have been supporting a colleague who seems depressed and lacking in confidence. You attend a cardiac arrest call. They are really upset and saying “he’s going to die!” What are the challenges of this situation?

Problem 3 During a busy shift you review a patient who has a probable UTI and chart Augmentin. They later become hypoxic and are taken to the CT scanner ?PE They arrest in the scanner and a review of the situation determines they have had an anaphylactic reaction to Augmentin, which was listed in the allergies box of their drug chart What was the error here?