Use of Medical Simulation to Explore Equipment Failures and Human-Machine Interactions in Anesthesia Machine Pipeline Supply Crossover

Identifying intraoperative events in a simulated laparotomy video: a multinational study of inattentional blindness among anesthesiologists

PURPOSE

Medical errors may be occasionally explained by inattentional blindness (IB), i.e., failing to notice an event/object that is in plain sight. We aimed to determine whether age/experience, restfulness/fatigue, and previous exposure to simulation education may affect IB in the anesthetic/surgical setting.

METHODS

In this multicentre/multinational study, a convenience sample of 280 anesthesiologists watched an attention-demanding video of a simulated trauma patient undergoing laparotomy and (independently/anonymously) recorded the abnormalities they noticed. The video contained four expected/common abnormalities (hypotension, tachycardia, hypoxia, hypothermia) and two prominently displayed unexpected/rare events (patient's head movement, leaky central venous line). We analyzed the participants' ability to notice the expected/unexpected events (primary outcome) and the proportion of expected/unexpected events according to age group and prior exposure to simulation education (secondary outcomes).

RESULTS

Anesthesiologists across all ages noticed fewer unexpected/rare events than expected/common ones. Overall, younger anesthesiologists missed fewer common events than older participants did (P = 0.02). There was no consistent association between age and perception of unexpected/rare events (P = 0.28), although the youngest cohort (< 30 yr) outperformed the other age groups. Prior simulation education did not affect the proportion of misses for the unexpected/rare events but was associated with fewer misses for the expected/common events. Self-perceived restfulness did not impact perception of events.

CONCLUSION

Anesthesiologists noticed fewer unexpected/rare clinical events than expected/common ones in an attention-demanding video of a simulated trauma patient, in keeping with IB. Prior simulation training was associated with an improved ability to notice anticipated/expected events, but did not reduce IB. Our findings may have implications for understanding medical mishaps, and efforts to improve situational awareness, especially in acute perioperative and critical care settings.

Failures of the Oxygen Supply

Oxygen supply failures are potentially life-threatening and are often associated with death or brain damage. Knowledge of how oxygen is supplied is essential for understanding how failures are caused and their management. Even though safety mechanisms exist to reduce the likelihood of a supply failure, events still occur. Simulation studies have identified knowledge and performance gaps in management of supply failures. A straightforward approach to immediate management of these critical events is provided.

Inattentional blindness in anesthesiology: A simulation study

STUDY OBJECTIVES

Inattentional blindness is the psychological phenomenon of inability to see the unexpected even if it is in plain view. We hypothesized that anesthesiologists may overlook unexpected intraoperative events whereas medical students, lacking in intraoperative monitoring experience and knowledge, may be more likely to notice such events.

DESIGN

A simulation study using a video of a simulated septic patient undergoing abdominal surgery.

SETTING

A large academic center.

PARTICIPANTS

31 certified anesthesiologists and 46 upper-year medical students.

INTERVENTIONS

None. Participants watched a video of a simulated surgery and scored the abnormalities they saw.

MEASUREMENTS

These abnormalities included abnormal physiologic parameters consistent with the condition of the simulated septic patient, and two unexpected but plausible events: head movement and a leaky central line catheter.

MAIN RESULTS

Students were significantly more likely than anesthesiologists to notice head movement (p<0.001).

Retesting the Hypothesis of a Clinical Randomized Controlled Trial in a Simulation Environment to Validate Anesthesia Simulation in Error Research (the VASER Study)

Background

Simulation has been used to investigate clinical questions in anesthesia, surgery, and related disciplines, but there are few data demonstrating that results apply to clinical settings. We asked “would results of a simulation-based study justify the same principal conclusions as those of a larger clinical study?”

Methods

We compared results from a randomized controlled trial in a simulated environment involving 80 cases at three centers with those from a randomized controlled trial in a clinical environment involving 1,075 cases. In both studies, we compared conventional methods of anesthetic management with the use of a multimodal system (SAFERsleep®; Safer Sleep LLC, Nashville, Tennessee) designed to reduce drug administration errors. Forty anesthesiologists each managed two simulated scenarios randomized to conventional methods or the new system. We compared the rate of error in drug administration or recording for the new system versus conventional methods in this simulated randomized controlled trial with that in the clinical randomized controlled trial (primary endpoint). Six experts were asked to indicate a clinically relevant effect size.

Results

In this simulated randomized controlled trial, mean (95% CI) rates of error per 100 administrations for the new system versus conventional groups were 6.0 (3.8 to 8.3) versus 11.6 (9.3 to 13.8; P = 0.001) compared with 9.1 (6.9 to 11.4) versus 11.6 (9.3 to 13.9) in the clinical randomized controlled trial (P = 0.045). A 10 to 30% change was considered clinically relevant. The mean (95% CI) difference in effect size was 27.0% (−7.6 to 61.6%).

Conclusions

The results of our simulated randomized controlled trial justified the same primary conclusion as those of our larger clinical randomized controlled trial, but not a finding of equivalence in effect size.

Virtual reality in anesthesia "simulation"

Simulation in anesthesia is a field that has revolutionized the teaching outlook. The uncommon grave situations are no more unseen. The ability of these devices to test and give a taste of nerves to an anesthetist is actually preparing him for a safe future management when the need be. The role of simulation in testing a new device for its likely success in clinical world can be foreseen. Mastering a difficult skill no longer subjects a patient to danger. These advanced methods not only see how anesthetist responds to environment, but also how the OT environment reacts to him. The review highlights how technology will help us become technically sound clinicians for tomorrow.

Validation of an interactive simulation module to train the use of a laparoscopic insufflator

BACKGROUND

The purpose of this study was to determine construct and face validities of an interactive Web-based module for pneumoperitoneum and insufflator.

METHODS

Participants were recruited from surgical departments in 2 academic hospitals and 1 large nonacademic teaching hospital. They were stratified into 3 groups based on their laparoscopic experience (A, no experience; B, experience as assistant; and C, experience as primary surgeon). Within each group the participants were randomized into a training subgroup and a control subgroup. All participants performed a theoretical and a practical test. The training participants first completed the module before they performed the tests. The control participants immediately performed the tests. Results were compared between the training and control participants. All training participants filled out a questionnaire on their opinion about the module.

RESULTS

In total, 40 participants were enrolled in the study: group A consisted of 20 participants and groups B and C both consisted of 10 participants. The trained participants answered significantly more theoretical questions correctly (8.3 vs 6.6; P < .001), correctly identified more alarm causes (91% vs 86%; P = .014) and made significantly less errors in the practical test (1.5 vs 3.6; P = .001). All 20 trained participants rated the module fairly good and indicated the module to be of additive value to surgical training programs.

CONCLUSIONS

Training with the interactive web-based module on installation of a pneumoperitoneum and use of an insufflator has a positive effect on both theoretical and practical competence. Construct and face validities were established for this module.

Review article: simulation in anesthesia: state of the science and looking forward

PURPOSE

Within the field of anesthesia, simulation has been used as a tool for training and assessment for over 30 years. The purpose of this review is to evaluate the state of the science in terms of its effectiveness as an approach to both training and assessment in anesthesia. Articles in the area of simulation and anesthesia published up to and including 2011 were reviewed for inclusion in this narrative review.

PRINCIPAL FINDINGS

Simulation-based training is generally well received by participants, it can lead to improved performance in subsequent simulation events, and some transfer of learning to the clinical setting is evident. There is also some early evidence that well-designed performance assessments could have the required reliability and validity to support high-stakes examinations. However, further work is needed in order to set standards and establish the predictive validity to support such assessments.

CONCLUSION

For simulation to realize its potential impact, further research is needed to understand how to optimize this modality of learning more effectively, how to transfer knowledge of research findings to practice, and also how to broaden the simulation modalities used in anesthesia. In future, the optimal use of simulation will depend on a clear understanding of what can and cannot be accomplished with simulation and its various modalities.

The study of factors affecting human and systems performance in healthcare using simulation

A large body of research using simulation in healthcare has focused on simulation itself as an object of research. However, simulation can also be used in research on human or system performance. It can be used to investigate the effects of performance shaping factors that would otherwise be difficult to study in the actual clinical setting due to practical constraints or ethical concerns. In this monograph, we illustrate various ways in which simulation has been used to study performance shaping factors. We also discuss possible directions for future research as well as methodological considerations for researchers engaging in this approach to study performance shaping factors.

Simulation and quality improvement in anesthesiology

Simulation, a strategy for improving the quality and safety of patient care, is used for the training of technical and nontechnical skills and for training in teamwork and communication. This article reviews simulation-based research, with a focus on anesthesiology, at 3 different levels of outcome: (1) as measured in the simulation laboratory, (2) as measured in clinical performance, and (3) as measured in patient outcomes. It concludes with a discussion of some current uses of simulation, which include the identification of latent failures and the role of simulation in continuing professional practice assessment for anesthesiologists.