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BMC Anesthesiology

, 16:4

Perioperative medicine and outcome

Abstract

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.

KeywordsSituation awareness Patient safety Human error analysis Accident analysis Anesthesia and perioperative care Critical care AbbreviationsÄZQAgency for Quality in Medicine

BDABerufsverband Deutscher Anästhesisten Alliance of German Anesthesiologists

CIRSCritical Incident Reporting System

DGAIDeutsche Gesellschaft für Anästhesiologie und Intensivmedizin German Society, of Anesthesiology and Intensive Care Medicine

ICUIntensive Care Unit

PACUPost anesthesia care unit

SASituation Awareness

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Author: Christian M. Schulz - Veronika Krautheim - Annika Hackemann - Matthias Kreuzer - Eberhard F. Kochs - Klaus J. Wagner

Source: https://link.springer.com/







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