Human factors

Description

Examples

Possible problem-solving strategies

Actionism

Spontaneous acts without consideration of goals

Thereby neglecting to perform necessary steps and overlooking relevant information

Case 24

Extubation of a patient during excitation phase with subsequent low pressure pulmonary edema

Conscious formation of goals

Setting of primary and secondary goals and the criteria needed to fulfill each

Priorities and goals must be communicated within the team

Activation level, low

Due to low level of personal activation, procedures were forgotten

Case 21

Lack of oversight of volume administration during a colectomy

Self–initiated stimulation during boring phases

For example: conscious anticipation of the worst-case scenario or preoccupation with solutions for fictitious problems

Attitude, overly optimistic outlook

Due to the readiness to take risks with the attitude “Nothing will go wrong,” no serious consideration is given in advance to serious possible complications

After an emergency arises, no alternative is available

Case 19

No anticipation of nose bleeding in fiberoptic nasal intubation

Case 25

No consideration of the connection between the inguinal hernia and the sepsis

Metacognition

Reflection on our own assumptions and motivations for the actions we take

After recognizing a dangerous assumption → the antidote is to verbalize “Complications arise with my patients, too.”

Attitude, state of resignation

Overwhelmed to the extent of mentally resigning from attempting to work anymore

Case 29

Endangering the patient during transport to CT

Critical self–reflection

Define and practice a stimulus for self-reflection: review the state of events out loud, ask for hints from the team members, pay special attention to advice

Availability heuristic

Conclusions are drawn from the diagnosis in most recent memory

Case 20

Low S_PO₂ values were only associated with hypoxia

Conscious information search, to find details which go against your own assumptions

Cognitive economics

Due to the scanty information processing, medications were mixed up during a routine situation

Case 10

The medication mix up lead to an overdose of ropivacaine, and consequently, infant CPR

Make sure you remain alert

Work through checklists

Check one another

Question assumptions

Read back medications before administration

Don’t make labels easy to confuse

Communication, unclear

Lack of shared language between various specialties leads to misunderstandings

Case 26

Incorrect interpretation/meaning of the definition of infrarenal aortal aneurysm

Establishment of a shared mental model

Communication of top priorities and delegation and coordination of tasks within “the big team”

Necessary requirements: One person must be designated as being responsible, usually of their own initiative

Verbalization of findings out loud in front of the whole team

Thereby, possible recognition of various interpretations

Decision-making, emotional

Simple coherences are not comprehended due to fully emotional decision-making

Case 23

The danger of a tube fire was not calculated, because the S_PO₂ decrease caused the O₂ to air ratio to be increased

Step back

Consciously take a step back and bring yourself mentally out of the situation. Then examine the situation again, mentally stress free – this allows an emotional trigger to be recognized

Practice the step-back ritual in advance

Metacognition after performing a step back (thinking about your own thoughts)

Question your own hypothesis

Critically recheck your assumptions

Search for information which could verify the worst-case scenario

Decision-making, under time pressure

When pressured for time, treatment options are forgotten or risks are not considered. The basis for the decision becomes incomplete/incorrect

Case 3