Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system

BMC Anesthesiology

Research Article

Veronika Krautheim¹  Eberhard F. Kochs¹  Annika Hackemann¹  Klaus J. Wagner¹  Christian M. Schulz¹  Matthias Kreuzer¹ 

[1] Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Germany;

关键词: Situation awareness;    Patient safety;    Human error analysis;    Accident analysis;    Anesthesia and perioperative care;    Critical care;   

DOI  :  10.1186/s12871-016-0172-7

 received in 2015-06-30, accepted in 2016-01-14,  发布年份 2016

来源: Springer

【 摘 要 】

BackgroundA loss of adequate Situation Awareness (SA) may play a major role in the genesis of critical incidents in anesthesia and critical care. This observational study aimed to determine the frequency of SA errors in cases of a critical incident reporting system (CIRS).MethodsTwo experts independently reviewed 200 cases from the German Anesthesia CIRS. For inclusion, reports had to be related to anesthesia or critical care for an individual patient and take place in an in-hospital setting. Based on the SA framework, the frequency of SA errors was determined. Representative cases were analyzed qualitatively to illustrate the role of SA for decision-making.ResultsSA errors were identified in 81.5 %. Predominantly, errors occurred on the levels of perception (38.0 %) and comprehension (31.5 %). Errors on the level of projection played a minor role (12.0 %). The qualitative analysis of selected cases illustrates the crucial role of SA for decision-making and performance.ConclusionsSA errors are very frequent in critical incidents reported in a CIRS. The SA taxonomy was suitable to provide mechanistic insights into the central role of SA for decision-making and thus, patient safety.

【 授权许可】

CC BY   
© Schulz et al. 2016