Medgadget editor Paul Pisklak, M.D., an anesthesia resident at Baylor, is attending the annual meeting of Society for Technology in Anesthesia. Here’s his first report.
The keynote speaker at this year’s Society for Technology in Anesthesia conference at The Venetian in Las Vegas was Colonel Jim Bagian, M.D., P.E., a physician and astronaut. Dr. Bagian gave a talk cleverly entitled “Patient Safety: It’s Not Rocket Science.” His unique broad view of the aviation and healthcare industries gives him a special insight into the subject at hand.
The main thrust of his argument is that a large percentage of adverse events that happen in hospitals are human and communication errors, i.e., misuse of the technology that we already have. One example he gave was from his former role as a VA safety official when a group of nurses came to him with an external pacemaker error. A patient was getting very bradycardic, but when they hooked up the pacemaker, it said “Error 004.” The nurses brought it to the hospital’s biomedical department staff, who simply took out and reinserted the battery. This workaround had been used for 8 years! Dr. Bagian ended up calling the manufacturer and addressing the root cause of the problem and having them update a software update. The gist of this story is the importance of addressing the root cause of device problems and not just “band-aid fixes.”
Another interesting anecdote that he shared had to do with vigilance. A group of radar operators in the military was offered a full month’s extra pay if they could have 100% accuracy at detecting enemy ships. It turned out that despite the huge incentive, the operators’ accuracy went down considerably after an hour, demonstrating the human propensity to get distracted at routine tasks – a fact that has considerable applicability to anesthesiologists, who spend hours monitoring for what can be minuscule changes. Of note, providing electric shocks to the chairs of the radar operators every 10 minutes increased vigilance dramatically!
Dr. Bagian drove this concept home with an interactive segment. To demonstrate the concepts of vigilance and “inattentional blindness,” he showed the following video. When you watch this, see if you can count how many times the ball is passed between people in white shirts.
Now there’s food for thought about the things that we have to think about and those that we don’t.
We will keep reporting from the STA conference…
Dr. Bagian bio link…
More info on inattentional blindness…
