Principal Investigator: Ken Catchpole, Ph.D., Medical University of South Carolina, Charleston, SC
Co-PI: James Abernathy, M.D., M.P.H., Johns Hopkins University, Baltimore, MD
AHRQ Grant No.: HS26625
Project Period: 09/30/18-07/31/23
Description: This lab’s overarching goal was to reduce anesthesia medication errors by assessing the anesthesia medication work system and identifying characteristics of technologies and interventions that would feasibly improve patient safety.

The specific aims were to:

1. Explore solutions to failures in diagnosis, selection, and prescribing of intraoperative anesthesia medication.
2. Develop methods to reduce failures in the preparation, administration, and recording of intraoperative anesthesia medication.
3. Understand and improve workspace design and safety culture to influence anesthesia medication selection and delivery.

The learning lab found that “medication error” is defined in multiple ways, focusing solely on patient outcome, causation, or both. Multiple definitions can lead to problems synthesizing, interpreting, and engaging in sense making about anesthesia medication safety. Specifically, this range of definitions leads to confusion between harm and its causes.

Through interviews and observations, researchers explored how decisions were informed by various devices, technologies, and information sources and how practitioners addressed unreliable information. The research team also found wide variability in decisionmaking strategies that can limit standardized approaches to medication safety. They studied how syringes are used, stored, and moved within an operating room (OR) and the limitations of incident reporting for determining causation. The team identified cramped workspaces, limited access to the patient and equipment, and lack of standardization across non-OR anesthesia settings as risk factors for anesthesia medication delivery.^1-4

These findings led to developing anesthesia workspace guidelines and OR workspace configurations presented through virtual reality.⁵ One of the three configurations was traditional and two were new. An evaluation of the configurations showed that the new ones significantly enhanced situational awareness, allowed continuous visual monitoring of the patient, and provided ample horizontal workspace for tasks.¹ 

Other interventions included the following^1,6-8: 

• The addition of an interactive educational program on academic detailing to boost reporting of errors and adverse events to the National Anesthesia Clinical Outcomes Registry was successful. There was a statistically significant increase in the number of reported events, from 55 in 2021 (preintervention) to 134 in 2022 (postintervention). Of the 36 certified registered nurse anesthetists who participated in the intervention, 18 had a positive change in reporting behaviors. The overwhelmingly positive feedback from participants, who most frequently selected the most positive scale response, underscores the effectiveness of the program intervention. 
• The development of medication icon labels featuring a graphical representation of the action of the medication, as well as tall-man lettering and color coding, made it easier to differentiate between medications. Audits showed high-use compliance during the implementation study and favorability by healthcare providers. The intervention’s success led to a project proposal to extend the development of icons for dose, route, and action, as well as in the intensive care unit. This work enhances the visualization of the state of the clinical system.
• The creation of a syringe organizational hub comprising eight holes with tapered wells allowed easy syringe insertion and removal while maintaining the ability to safely hold syringes. Researchers found that the hexagon-shaped hub reduced syringe movements and consolidated the location of drug delivery during its evaluation. Overall, it reduced the complexity of syringe storage, showing that a simple device can significantly affect OR workflow.

According to the lab, more opportunities remain to improve anesthesia medication delivery through the application of sociotechnical systems engineering and human factors principles.^1,9 Due to lockdowns associated with the COVID-19 pandemic, the lab’s development and implementation phases experienced delays and challenges with multisite data collection.¹ However, the lab adapted, using existing databases, data sources, and video recordings of OR work. It also relied on other data collection approaches, such as surveys and remote ideation approaches (e.g., MIRO online Post-It note application). This success paves the way for a more efficient and patient-focused anesthesia delivery system.

To date, this PSLL’s work has resulted in at least 22 peer-reviewed publications that have been cited in nearly 200 other publications, as well as posters and presentations at conferences in the United States and internationally.

Publications

2024

• MohammadiGorji S, et al. Anesthesia workspaces for safe medication practices: design guidelines. HERD 2024;17(1):64-83.
• Neyens DM, et al. The movement of syringes and medication during anesthesiology delivery: an observational study in laparoscopic surgeries. Appl Ergon 2024 Jul 1;118:104263.
• Sims H, et al. The impact of a novel syringe organizational hub on operating room workflow during a surgical case. Jt Comm J Qual Patient Saf 2024 Jul;50(7):542-544.

2023

• Lomax S, et al. Implementing human factors in anaesthesia. Anaesthesia 2023;78(7):916-917.
• Samost-Williams A, et al. Taking a resilience engineering approach to perioperative handoffs. Jt Comm J Qual Patient Saf 2023 Aug;49(8):431-434.
• Sims H, et al. The design and evaluation of a syringe hub for organizing syringes in anesthesia medication delivery. Hum Factors Health 2023 Dec 1;4:100049.

2022

• Alfred MC, et al. Anaesthesia provider perceptions of system safety and critical incidents in non-operating theatre anaesthesia. Br J Anaesth 2022 Apr;128(4):e262-e264.
• Biro J, et al. “One size” doesn’t “fit all”: understanding variability in anesthesia work practices. Hum Factors Health 2022 Dec 1;2:100026.
• Biro J, et al. Medication errors, critical incidents, adverse drug events, and more: examining patient safety-related terminology in anaesthesia. Br J Anaesth 2022 Mar;128(3):535-545.
• Cohen TN, et al. Using flow disruptions to understand healthcare system safety: a systematic review of observational studies. Appl Ergon 2022;98:103559. 
• Coppola SM, et al. Systems engineering-based framework of process risks in perioperative medication delivery. Br J Anaesth 2022 Dec 1;129(6):e168-e170.
• Lusk C, et al. Improving safety in the operating room: medication icon labels increase visibility and discrimination. Appl Ergon 2022 Oct 1;104:103831.
• Lusk C, et al. Reconsidering the application of systems thinking in healthcare: the RaDonda Vaught case. Br J Anaesth 2022 Sep;129(3):e61-e62.
• Tobin CD, Bridges KH. Systems safety in nonoperating room anesthesia locations. Curr Opin Anaesthesiol 2022 Aug 1;35(4):502-507.
• Xiao Y, et al. Patient safety learning labs: effective collaborations for enhanced patient safety. Proc Hum Factors Ergon Soc Annu Meet 2022 Sep;66(1):1581-1585.

2021

• Catchpole K, et al. Frontiers in human factors: embedding specialists in multi-disciplinary efforts to improve healthcare. Int J Qual Health Care 2021;33(Supplement_1):13-18. 
• Herman AD, et al. Morbidity, mortality, and systems safety in non-operating room anaesthesia: a narrative review. Br J Anaesth 2021 Nov 1;127(5):729-744.
• Perry SJ, et al. 'Strangers in a strange land': understanding professional challenges for human factors/ergonomics and healthcare. Appl Ergon 2021 Jul;94:103040.

2020

• Biro J, et al. Illuminating the decision-making strategies of anesthesia providers in challenging cases. Proc Hum Factors Ergon Soc Annu Meet 2020 Dec;64(1):653-657. 
• Biro JM. Illuminating the Naturalistic Decision-Making Processes of Anesthesia Providers To Inform Medication Error-Reducing Interventions. Clemson Open; 2020, All Theses, 3421.
• Catchpole K, et al. Understanding the limitations of incident reporting in medication errors. Br J Anaesth 2020 Oct 1;125(4):e343-e344.
• Herrick HM, et al. Impact of flow disruptions in the delivery room. Resuscitation 2020 May 1;150:29-35.

References

1. Catchpole K. Final Report: Identifying and Reducing Errors in Perioperative Anesthesia Medication Delivery. Charleston: Medical University of South Carolina; 2024, pp. 1-20.
2. Biro J, et al. “One size” doesn’t “fit all”: understanding variability in anesthesia work practices. Hum Factors Health 2022 Dec 1;2:100026.
3. Biro JM. Illuminating the Naturalistic Decision-Making Processes of Anesthesia Providers To Inform Medication Error-Reducing Interventions. Clemson Open; 2020, All Theses, 3421.
4. Coppola SM, et al. Systems engineering-based framework of process risks in perioperative medication delivery. Br J Anaesth 2022 Dec 1;129(6):e168-e170.
5. MohammadiGorji S, et al. Anesthesia workspaces for safe medication practices: design guidelines. HERD 2024;17(1):64-83.
6. Sims H, et al. The design and evaluation of a syringe hub for organizing syringes in anesthesia medication delivery. Hum Factors Health 2023 Dec 1;4:100049.
7. Sims H, et al. The impact of a novel syringe organizational hub on operating room workflow during a surgical case. Jt Comm J Qual Patient Saf 2024 Jul;50(7):542-544.
8. Neyens DM, et al. Using a systems approach to evaluate a circulating nurse’s work patterns and workflow disruptions. Appl Ergon 2019 Jul:78:293-300.
9. Lomax S, et al. Implementing human factors in anaesthesia. Anaesthesia 2023;78(7):916-917.