Ryan D. Lewis MD MHA Capstone Advisor: Ayse Gurses, PhD, Assistant Professor, Department of...
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- Slide 1
- Ryan D. Lewis MD MHA Capstone Advisor: Ayse Gurses, PhD,
Assistant Professor, Department of Anesthesiology and Critical Care
Medicine The Johns Hopkins School of Medicine Can a Device-Use
Checklist Reduce Medical Errors in the Operating Room? A Literature
Review
- Slide 2
- Overview Introduction Methodology Results Discussion
Summary
- Slide 3
- Device-Use Error Human Limitations (memory distraction) Device
Complexity (multiple parts multiple steps) System Limitations
(teamwork communication) Device-Use Error
- Slide 4
- Devices Are Becoming More Complex Image Source: The Vein and
Vascular Institute of Tampa Bay; tampavascularsurgeon.com
- Slide 5
- Classification/Regulation FDA Device Classification Class I
Class II Class III highest risk IFUs
- Slide 6
- Medical Errors Device-Related Errors Surgical Device Errors
Complex-Invasive Surgical Device (CISD)Errors
- Slide 7
- CISDs Image Source: Dr. Grobelney performs endovascular
surgery; chicagovascularsurgery.com; Gore Neuroprotection System;
touchcardiology.com
- Slide 8
- CISDs 20 potential adverse events listed 60 (approx) procedural
steps Image Source: The Gore Helex Septal Occluder; gore.com; The
Helex Septal Occluder; scielo.br
- Slide 9
- Checklists in Aviation Image Source: Wright brothers airplane,
xtimeline.com
- Slide 10
- Checklists in Aviation Image Source:Test flight of B-17; B-17
test flight crash How the pilots checklist came about,
atchistory.org
- Slide 11
- Image Source: Approved B-17F and G checklist, pilots duties in
red, galbreath.net
- Slide 12
- Could CISDs Benefit From Checklists? Image Source: Glass
cockpit, amevoice.com; Printable wedding checklist,
portaweddings.com; Robotic surgery, spectrum.ieee.org
- Slide 13
- Methodology Literature search for articles relating to:
Checklists in medicine, surgery, for surgical devices
Device-related adverse events Distributed cognition theory Adverse
events and memory/distraction Human error theory Instructions for
use Others No articles found describing checklists for CISDs
- Slide 14
- Results Description of the public health problem Magnitude of
the problem Causes and determinants Prevention and
intervention
- Slide 15
- Magnitude of the Problem Medical Errors Device-Related Errors
Surgical Device Errors Complex-Invasive Surgical Device
(CISD)Errors 44,000-98,000/year = $24 billion 1 83.7/1000 hospital
visits 2 ??? MAUDE/manufacturers database 1.To err is human:
Building a safer health system - summary [Internet].; 1999.
Available from:
http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-
Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf.http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-
Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf
2.Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The incidence and
nature of surgical adverse events in colorado and utah in 1992.
Surgery. 1999 Jul;126(1):66- 75. = 1.5 jetliners crashing every day
1
- Slide 16
- Causes and Determinants Lack of experience or competence with a
procedure (53%) 1 Breakdown in communication (43%) Fatigue (33%)
Interruptions/distractions during a procedure Inappropriate
protocols 1. Gawande AA, Zinner MJ, Studdert DM, Brennan TA.
Analysis of errors reported by surgeons at three teaching
hospitals. Surgery. 2003 Jun;133(6):614-21.
- Slide 17
- Human/System Limitations 7 2 Image Source: James Reasons Swiss
cheese model, thereliabilityroadmap.com; Seven chunks plus or minus
two, thelatherapistblogspot.com; Image of a person doing math with
a paper and pencil,tamu-commerce.edu
- Slide 18
- Prevention Greater than 50% of surgical injuries are
preventable 1 1. Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The
incidence and nature of surgical adverse events in colorado and
utah in 1992. Surgery. 1999 Jul;126(1):66-75. Image Source: A
central line placed in a patient, blog.timesunition.com
- Slide 19
- Intervention Image Source:WHO Surgical Safety Checklist,
who.int
- Slide 20
- Discussion Checklists work Devices are becoming more complex
Limitations of the literature Criticism of checklists Future
studies
- Slide 21
- Summary CISD-use errors occur at some undetermined rate The
causes and determinants for surgical errors are likely the same for
CISD-use errors A device-use checklist could be explored as an
intervention