Designing for Safety: Applying Human Factors in Anesthesia Care

Hello everyone and welcome to the designing for safety webinar collaboration on human factors and anesthesia. We are co uh the patient safety movement foundation is co-hosting this webinar with the American association of nurse anesthesiology and we want to thank Dr. Ward for uh chairing this webinar. So please Dr. Ward, if I can hand this all off to you. >> Great. Thank you very much and hello everybody. I'm delighted to be here today. My name is Marie Ward and I am the chairperson of the Irish Human Factors and Ergonomics Society. I'm a chartered member of the um institute in the UK and I'm a council member of the International Ergonomics Association. I work full-time as an embedded human factors practitioner in a large public hospital in Dublin and I'm also faculty on the um fellowship for the patient safety movement foundation. So I'm delighted to chair this webinar today. It's a real honor and um we have two great panelists here today. So we have Dr. Suzanne Wright from Old Dominion University and professor um Naj Mescati who is a professor of engineering and international relations at the University of Southern California USC. So both panelists are going to firstly um introduce yourselves which will be great and then um we have some really interesting questions lined up for our panelists. So Suzanne I'll hand over to you first if that's okay. >> Yes. Thank you. I'd like to thank you Dr. award and the patient safety movement foundation as well as the A&A for the opportunity to be a part of this. I am a certified registered nurse um anest since 2003 and a tenure associate professor at Old Dominion University's Elmer School of Nursing. I am a fellow of the American uh uh association of nurse andists and a former chair of the department of nurse anesthesia at Virginia Commonwealth University where we um offered a simulation intense training program which kind of piqued my interest in human factors and patient safety. I currently serve as the chair of the patient safety advisory panel of the ANA and I'm also a member of the scientific executive committee of the anesthesia patient safety foundation. >> Great. Thank you so much Suzanne for for the introduction and um Naj would you like to introduce yourself please? >> Sure. Thank you Dr. Ward and it's so nice to meet you Dr. Wright. I'm Naj Mashkati. I'm a professor of engineering and international relations at the University of Southern California. I've been a faculty full-time faculty here for 40 years, 40 long years, sorry. And my background is in industrial engineering human factors with the healthcare industry. I have been a commissioner with the joint commission for nine years and then currently I'm on the governance board of the patient safety movement foundation that's why uh I'm here as patient safety movement foundation is a co-convener with a a na I have done a lot of work in human factors with safety critical system I'm a fellow with human factors and ergonomic societ society in US and I've done a lot of work with them in these areas and it's a pleasure for me to be here with the two distinguished lady. >> Brilliant. Thank you so much and we just want to state at the beginning of the webinar that the three of us have no conflicts of interest to declare. So let's let's get started. So I love human factors. Very passionate about it. I think it's a great topic. Delighted to see this happening. Um but just not not everybody is as passionate or as about it or understands it I suppose as we do. So there are lots of terms used and I I I'm based in Europe and you know even across the United States and Europe there are different terms used for human factors. So we have you know human factors, human factors engineering, human factors ergonomics, ergonomics and these are terms maybe that um clinicians and health care professionals hear but might not fully understand. So I suppose first of all let's define what we're talking about and and especially in this context of of anesthesia. So Suzanne maybe I'll go to you first. So how do you define these terms and how do you what do you find helpful for clinicians to understand these terms? >> Yeah, thank you so much uh Dr. Ward. I'm excited to be here to talk about this topic because I really think it's at the heart of anesthesia patient safety. the human factors, human factors engineering, ergonomics, all the terms that you introduce here are used almost interchangeably in everyday practice. I would say probably more nuanced um in in the expert expert arena of human factors. But there are subtle distinctions, but they all share the same fundamental goal of designing systems, technology, environments, and maybe workflows that support human performance and reduce the likelihood of human error. In the context of anesthesia practice, human factors is the science of understanding how anesthesia providers interact with factors such as basic monitoring um and monitoring that's more complex, the technology, all the clinical tasks that have to be done throughout a surgical case, the environment, and also how we interact with one another. I think it even recognizes and emphasizes that even experienced and highly skilled clinicians have physical and cognitive limitations whether they believe that or not. Um our attention is finite. Our memor is imperfect. Our performance changes with the stress, fatigue and frustration that is with us almost daily in the operating room. And I think uh rather than expecting clinicians to be flawless, human factors focuses on designing the systems that make it easier to do the right thing and much more difficult to do the wrong thing. So every time we standardize medication labeling or use waveform capnography to confirm proper placement of an endotracchial tube, uh we are essentially applying human factors principles. And these interventions, as we know, don't make clinicians smarter, but helps make the system safer. >> Oh, that's great. Thank you, Suzanne. And I love that focus on design, you know, because that is ultimately what what I believe human factors is about. It's really designing to support humans in these very complex systems. So, Nash, would you like to add anything to that or anything that has struck you over the years about confusion over human factors? I think Susanna has said it all. Suzanne, that was excellent. I was just trying to remember what you said and it was just perfect. The only thing that I will add to her excellent definition of human factors is what I teach here at USC in our aviation safety program. And in my uh graduate undergraduate classes as for the first session I say basically in human factors we want to understand and address humans needs limitations and capability both physical and psychological one. Understand and address that in the design of our workplaces and system. Because what we are trying to do and try to understand and try to address is try to match the human operator being a aircraft pilot, a nuclear plant operator or a a nurse to the system that they are working with. And this match is very important because I remember a definition by my late mentor professor Yans Rasmusen. He said human error can be considered as those instances of human machine or human task mismatches. Human machine and human task mismatch. The only way that we could provide a perfect match between these two systems components human and machine or human and technology is to understand this side which is the human component needs limitations and capability both physical and psychological one and I think what Suzanne said applies to every domain and context that we apply human factors. That's great. And just um you know I I think and I hope that some human factors practitioners will watch this webinar as well you know and some some people might say well why you know why do we need human factors in in a practice like healthcare and especially in anesthesia. I mean maybe you know would you human factors is often talked about in terms of other industries like aviation, nuclear power or um engineering but maybe for the non you know healthcare or non-medical people who might be listening Naj would you give an overview of of anesthesia and and like why why anesthesia why is human factors important um you know because we're talking about you're talking about human machine interface we don't think of machines I suppose in terms of healthcare. So maybe just give >> I I can speak based on my experience and observation. I have been to operating room in a open heart surgery and I've worked with a lot of anesthesiologist and I should name the late chair of our department of anesthesiology at US Dr. Philip Lum that has been a mentor to me and we talk a lot about that when wherever you have the human operator that they need to run a piece of equipment which you are using that in the case of perfusion in anesthesiologist or you need to go through a work process in order to do a job. In the case of anesthesiology in the operating room there are equipment that you are using there are medicine that you are using that there are people that you need to interact with all these components they need to have interfaces if a piece of information falls through the crack we have that mismatch if we don't have perfect match between human operator and the system and it those mismatches are potential for error and that's why For example, if you I I work on a design of the interface user interface for a perfusion pump for operating room and the same principles that apply for the design of the display and control that toggle switches, the rotary knobs and others. The same principles and tools and techniques apply to design of the cockpit of one of these aircrafts that are sitting here or the control room of a nuclear plant in Fukushima that I have a photo of it when I was there. See that the principles are the same but the areas of application are different. I think Suzanne being a anesthesiology nurse she could tell more about the specifically about anesthesiology. Yeah, thank you so much. Thank you so much, Naj. I think you uh are very very uh well familiar with the anesthesia working environment in the operating room. But I think you know about organizations that are set up uh for normal accidents like way back Charles Perau in the 70s talked about um organizations that are complex and tightly coupled and have the potential for catastrophe. When you think about anesthesiology and all of the components that are operating at the same time, I think it is an a a discipline that it has inherent risk factors and complexity that could be set up that way. And you highlighted a b many of the factors that we have to contend with on any given day all day long. managing a patient's airway, oxygenation, ventilation, their circulation. Uh many even on a simple anesthetic case case, a patient can receive up to 30 medications that have to be given the right dose the right way over the right amount of time. Um all of these things are going on at one time. So we make hundreds of decisions often in the thick of uncertainty and often under significant time pressure. We become fatigued, distracted, interrupted, overloaded, and frustrated at times. Um, all of which can contribute to the loss of situation awareness. And human factors is essential because it recognizes that even highly skilled and experienced people have not seen it all and have predictable human limitations. Even if uh a nurse and nest has been working for 30 years, they still haven't seen it all. and we run into this idea of trying to manage unexpected things. Um and and so it's really a lot to try to contend with. Human factors helps us tease all that apart so that we can have some effective way of approaching all this complexity. Um so ultimately human factors here shifts our thinking from asking who made a mistake to why did they make the mistake or why did they recover from uh the mistake to prevent harm. And focusing on this takes us away from the naming, the shaming and the blaming so that we can actually improve a system so that the next patient wouldn't have to suffer from from harm. >> And if I may add one more example which I I learned that from the late Dr. Philip Lum and I think the job of nurses in anesthesiology sometimes could be even more difficult and more uncertain that airline pilots and this is what Dr. Lam told me he's watching from heaven. He said in in the case of a when an aircraft comes down for landing at LAX Los Angeles airport, the runway is always the same place and it doesn't change the elevation. It doesn't change the direction and that he said for every patient that we work that landing script could be different. It could move. It could change the direction. It could go up and down. That's why he said that every case that we deal with is a special case. There is not that much level of a standardization that you have that in aviation because the landing strip at LAX is always at the same location and you always land over there. He said that doesn't work in aniology and I always remember that. That's what I have developed a lot of respect for your profession >> and I think that goes the same with putting someone to sleep. In fact, when I teach the graduate students here at Old Dominion University, I say going off to sleep is the takeoff. You know, maintenance of anesthesia is the, you know, cruising at 40,000 ft. And I always uh talk to them about, you know, what's your plan for coming in for the landing. We have to think through everything that could possibly happen. Um, and then things could still happen beyond what we think could possibly happen. So, we're always trying to stay one step ahead. So, I appreciate that last comment there. It's it's really interesting to to listen to you both, you know, because sometimes people say the lessons from human factors don't transfer to healthcare. Um, and I just would love your reflections on that because anesthesia has been at the forefront really of translating human factors into healthcare. So why why do you think that's the case? like why do you think anesthesia has in particular embraced so much of human factors and and Susanna I might start with you on that one? >> Sure. I even remember training 25 years ago. So that was you know quite some time ago and I learned in my formal program about human factors and patient safety uh Dave Gaba Charles Perau uh Jensen Resmuse and all of these folks about human factors. It was pretty early on and I think anesthesia is often described as one of healthc care's greatest patient safety success stories uh because it was the first specialty to really champion patient safety as a specific focus in the early to mid 1980s. For example, safety began to be talked about. During this time came the anesthesia patient safety foundation and also significant advances in technology including pulse oximry and capnography and failsafe mechanisms for the anesthesia machine which enabled real time monitoring of oxygenation and ventilation and made it nearly impossible to deliver a hypoxic mixture of anesthetic gases to a patient. Other standards and guidelines for safe practices soon followed including the American Society of Anesthesiologists difficult airway algorithm and the ANA standards for office-based anesthesia practice. So we started to see some standardization really early on. And then in the late 1980s of course um highfidelity human patient simulators were being incorporated into training programs uh so that anesthesia providers could have an opportunity to be exposed to be desensitized to and experience what it would be like to manage a very rare but incredibly critical anesthesia event. And this changed a lot in our in our training. Uh in the mid 1990s, the national patient safety association which was modeled after the anesthesia patient safety foundation was established and of course that was followed by the very well-known 1999 report by the institute of medicine to air as human which further laid the foundation for integrating human factors into healthcare on a broader level. So I'll end here acknowledging that anesthesia has become a leader in patient safety but our work to avoid preventable harm is far from finished. >> Yes. And and as you've worked across lots of industries like why do you think anesthesia is at the has been at the forefront in the adoption of human factors in healthcare? I suppose >> uh as Suzan mentioned anesthesiology and anesthesiologists they have had a lot of contribution in this area. She mentioned Dr. David Gaba at Stanford that he was has been a pioneer in application of some of this concept and there is a related concept called high reliability organization HRO which David Gaba has done a lot of work to bring that concept which is started from looking at the operation of the deck of aircraft career to anesthesiology and apply that to this. One of the reason I think anesthesiology in compar with aviation was a little bit late comer. Uh the the human factors started in in aviation industry and flourished over there. But anesthesiology as a field as a profession they picked it up as Suzanne mentioned something near 30 years ago or so. But they really fast forwarded that and right now they are becoming almost one of the pioneers in this area. One of the reason I think they became so interested in human factors because a very high potential for error and in during the in in the operating room because maybe the same shape the same color medicine or the problem I remember that Dr. Lum told me about these different hoses and their hookups so that they standardize that that you don't mix one with another one. There have been a lot of tools and techniques in human factors that we use that in aviation medicine for example to minimize the chance of error during the maintenance that could be applicable to anesthesiology. And as I mentioned to you when it comes to the human machine interface design it doesn't make any difference is that interface in a cockpit of an aircraft that are two same shaped toggles to each other sitting side by side or two same shaped liver that you may grab the wrong one or those two same shaped liver are sitting on a profusion pump or anesthetic equipment or any other place or on the stove. of your burner. There is a very interesting old experiment by the founding father of the field of ergonomics in US and fun Japanese that he looks at the design of the burners and the knobs that they control them and the concept of compatibility in design started from there. The compatibility in design applies to designing a burner on a stove as well as anesthetic equipment. Yeah. So what I'm hearing I suppose from from you is that anesthesia as a practice it's very high risk you know part of healthcare but also there is potential to standardize and potential to introduce these concepts like high reliability. Um but just we'll come to the kind of the the design and the higher reliability piece in a moment but um you both mentioned you know just the the concept of human error and um and I suppose you know we are trying to human factor shifts the focus from human error to human um you know contribution and what we contribute as humans and capturing error and capturing mistakes before they they become an issue. But the the background piece to that is culture. You know it is safety culture and psychological safety in particular. So um I suppose when something goes wrong we we rather than ask who made the mistake we we as you say Suzanne ask you know what happened or why did it not go right today you know um as opposed to what went wrong. So, so maybe just could you speak a bit to that um that idea of of you know moving that focus um and why is that important? Why is it important to move away from from blaming people for making mistakes and maybe na I'll start with you on that one and and move to Suzanne then >> thanks as you said Dr. where the issue of human error has been with us since the early time of the aviation. The the the garbage can model of the pilot error has been used. But really if you investigate the root cause of some of these errors, they are really what I call that design induced error. And if we fix the design at the interface level, we may able to uh reduce and to some extent eliminate maybe some of the source of error. However, there is also another thing that you mentioned the issue of culture and safety culture. Psychological safety has been promoted. It's one of the dimensions of safety culture as was proposed by professor Jim Rezen in his seminar book called managing risk managing organizational accidents. managing risk of organizational accident and in my judgment safety culture or the culture of safety is really foundation for every other thing that we do in a company or in an organization. In the case of a two Boeing crashes 737 that between the two of them Lion Air and Ethiopia and killed 346 people FAA at the request of Congress created a expert panel yours truly was a member of that expert panel on Boeing. We looked at Boeing safety culture safety management system and its relationship with FAA. One of the fundamental findings that we had was safety culture is really the foundation for safety management system SMS. There is a similar concept of SMS applied in medicine and other safety critical industry. If we don't have a healthy strong safety culture, every other intervention that we do it will work. But they are will be funded on a quick sand. They were not last. That's why I use safety culture as a foundation. And few years ago in a letter to editor in economist that got published about healthcare, I analogized safety culture with the immune system of human body. The same way that the immune system of human body fends off diseases and pathogens, that's the same way that a healthy safety culture works with a with an organization. >> Thank you. Thank you. N and and Suzanne, just it sounds like from what you you said already that you have managed to to move away from that kind of blame culture. I'm just just wondering, you know, how um do you think you have and what difference has that made then? >> Yeah, I I I I would have to say again, these are my thoughts. This is not empirical evidence, something hard to study, but I feel like we have a we have some more work to do there. I think there's something that, you know, we could have a whole another webinar about and that is the medical malpractice system that kind of um surrounds the practice of medicine whose focus is on pointing the fing finger in the name shame and blame game and providers are not um providers are very aware of this influence. So I think that in some way has some impact on providers still looking at who who made the mistake and what did they do and I would never do that and there and that is a pretty pervasive and palpable in the operating room just about every day. So I think that you know the original question I agree that this is one of the most important distinctions in patient safety is human factors versus human error because human factors focuses on the performance and human error seems to you know focus on the human. Uh so the human error approach is who and what human factors again ask the different question. Why did it make sense for a well-trained, well-intentioned clinician who knows better to do what they did at that moment and what was happening in the system around them. We need to slow down and ask that question more often. Most anesthesia professionals come to work every day hoping to do a great job. They've trained for years and years and years and years uh to make um significant positive differences in patients lives. yet many of them find themselves, you know, in front of a jury with the fingerpointing, you know, how could this possibly happen? So, we we really do need to steer the ship more um towards looking at what, you know, how was this person set up to fail and then have leadership that's committed to making those changes, which uh can be very difficult. So the reason this matters is that blaming individuals um may make us feel like we're doing something and addressing the issue and somehow making things right, but it rarely prevents the next event. Understanding the why and then improving the system does. >> Yeah. And I suppose for that for that then that needs you know a space where we all feel we we are safe to speak up or say safe to say listen I made a mistake or or safe to challenge a colleague and say I don't think what you're doing is is appropriate. Um and that's that's this idea of psychological safety um within our team but also the the wider safety culture. So I suppose Suzanne like what what role do you think clinicians especially you know given your background nurse and um nurses you know how how can we build that environment for each other you know how can teams create that environment that sense of psychological safety where we can discuss near misses they don't have to become incidents or accidents >> absolutely well I think alongside supportive leadership and organizational systems modeling safety behaviors is one of the most influential actions an individual anesthesia professional can take to strengthen a culture of safety. Behaviors like we've we've been talking about such as speaking up when it's uncomfortable. For instance, in the operating room, it's no secret that um they the surgical team um can listen to some pretty loud music. uh sometimes that may not be your brand of music or may be way louder than you're comfortable with. It is really up to us to to be able to um work in an environment where we can say, "I really need you to turn the music off now and I'll let you know when it is a good time to turn it back on at a reasonable level." Um or questioning a nurse. U Mary, did you put the straps on the legs? oftentimes what what I see time and time again is I'm sure she put the straps on the legs. Well, we're assuming that when we really need to address the patient or the provider by the name and hold them accountable for their role in keeping that patient safe. Now, we can encourage questions and invite input from other team members. oftentimes I'll find myself in an operating room doing cases that I'm not very familiar with and I'll uh reach out to the circulator and say I'm not in this room very often. If you see me doing anything or if you have a question about anything that I'm doing please you are welcome to let me know. visibly using checklists or cognitive aids, performing thorough pre-operative assessments and equipment checks, even if it means it's going to be a slight delay uh starting that starting that case. Uh conducting thoughtful transfers of care, we know that these are vulnerable times when a patient's coming from an operating room into a recovery room. That communication of critical information sets the patient up for either success or maybe um harm. So we can speak up and model behavior such as I don't know the answer to that question but I could use your help getting the answer to that. A little bit of humility goes a long way. And certainly as we've just started to introduce reporting near misses without assigning blame. We need to reflect on what went well in a complex case when oftentimes we do very complex cases and we don't say anything about why it went well. uh so we can highlight that that's a missed opportunity to highlight things that we can amplify to carry on to the next case. So really um you know modeling these safety behaviors and then other people see that and then other people see that and I I believe that's how things get adopted. Ultimately a strong safety culture isn't measured by how rarely people make mistakes. It's measured by how quickly and effectively we can recover from error so that small problems don't become larger and that we can prevent uh patients from um suffering for sometimes a lifetime. Every member of the team has the authority and the responsibility to protect the patient and they need to know that. One more thing on psychological safety and I'll end there is the safest operating rooms aren't ones where everybody agrees. In fact, they're the ones where everyone feels like they can respectfully disagree uh when the patients welfare depends on it. >> There's some great great wisdom there, Suzanne. you know, just in in as as clinicians and fellow clinicians and teammates being able to um model behavior, but as leaders as well, you know, that sense of humility and um and I love always love that idea of, you know, celebrating success and celebrating when we when we get things when we get things right. Um, Naj, the the the ways that aviation, you know, and other industries have used to promote being able to speak up or being able to uh challenge if you feel things are drifting into an unsafe space or um being able to challenge the pilot or, you know, do you think those have have brought benefit to health care or would you in terms of building that sense of psychological safety? You're on on mute. to >> sorry I coughed that's what I I I mute myself I think there is a lot of lessons that we can learn when it comes to safety culture from other industry which is equally applicable to healthcare industry and in the context of operating room anesthesiology this concept of safety culture started or being very much promoted primarily by the nuclear power industry. In fact, I always carry this booklet with me. There is an organization called Institute of Nuclear Power Operation that they work with the regulator nuclear regulatory commission and they created this thing which is called traits of healthy safety culture. We have been talking about psychological safety. Psychological safety is one of the dimensions of this traits of healthy safety culture which is called respectful work environment. But there are other traits like questioning attitude for example and and some eight or nine traits depends on which version you use. This concept of safety culture which is started by this uh industry now has been migrating into other industry. For example, oil and pipeline industry, they are also using the same traits. Uh the uh offshore drilling industry, I was involved with the investigation of the BPD water horizon. They are also warming up to these traits of healthy safety culture and railroad industry FRA, Federal Railroad Administration, regulator also embracing that. One of my uh advocacy while I was on the board of the joint commission was I was trying to get the CMS in United States and the joint commission and other organization like AA NA to get together and develop something which is called traits of healthy safety culture for healthcare industry. I think we have bits and pieces over there, but we need something in this industry for the regulator and the industry trade association like IMPO or NEI to come to the agreement and develop that. I think it's a it would be a big contribution to patient safety and quality if we can do that that the both the regulator and the major industry operator like American hospital association American medical association in US they could get together and come up with a mutually agreeable traits of health and safety culture for healthcare industry. Yeah, I think that's a great yes, a great idea. Um, just on the Suzanne, I might go back to you on that one, you know. So, how do the different checklists like in in practical terms like you know, how do they work and do you feel that they do contribute to promoting those healthy traits? >> Checklist specifically are are a great example. I published an article a few years ago on trying to organize the tasks that are needed to be done between tracheal intubation and surgical incision. This is a very short amount of time and a lot of tasks need to be done before uh we you know head up to cruising altitude. So it organized all this information and what I learned from there just personally but also in sharing this checklist is that it reduces the um cognitive load. It kind of distributes uh redistributes this heavy cognitive load um over time where you can anticipate uh the things that you're going to need and you don't you can your mind is free then to be able to deal with things that may be unexpected during that very high task load. So checklists I think you know we use the word so much that people think checklist but it really is a an effective tool um so that we don't have to rely on memory and attention alone. We just know that during this time I need the checklist and it just draws you right to it. And I I think it's highly effective in organizing important tasks and minimizing opportunities um to forget very important things that may be very difficult to do then once the surgical incision happens. >> Yeah. And I think it also shows people that we are human, you know, and that we do need these aid memoirs and that it's okay to to use them. >> Yes. Yeah. And a very basic thing to remember I don't want to forget is um you know the reason we we put patients off to sleep with medication through the IV most of the time. Well, that's a very potent but very short acting medication. How they stay asleep is reaching over and turning on the anesthetic gas. And do you know why we do that? The only reason we remember to do that is memory. There's no one tapping on your shoulder. There's no alarm that goes off that says, "Hey, don't forget to turn the gas on." Uh we re we just simply remember to turn that gas on. And that I think is a significant vulnerability uh where we should have some better checks and balances that once we intubate someone and that initial medication's wearing off, there should be a loud sign that says don't forget to turn the gas off. uh because many patients are paralyzed at that time and obviously nobody would like to be paralyzed in waking up at the same time. So just a small example of of checklists and how they can keep us out of trouble. >> Well, it is yeah it's a great thing to move on on. I suppose you know we deliberately wanted to focus a bit on safety culture because N you mentioned safety management systems and a lot of people forget the safety culture piece and it's a huge piece of safety management systems. Um but just I suppose moving you know that's a that's a challenge Suzanne you talk about in terms of anesthesia and like what are those the most significant kind of challenges from a human factors perspective facing anesthesia as a discipline like what what what do you think they are maybe Suzanne um some of those like and and then Naj you could you could come in on that as well. Yeah. So, we're talking about human factors, which are the factors we explore that impact human performance. And what I see just off the top of my head that I think are most palpable on most days in the operating room still, even given our um you know, safety record and advances and and our um adoption of human factors thinking are things like the cognitive overload. you know, during a single anesthetic, we're simultaneously managing so many things and there are conflicting demands on our attention. We're trying to provide uh life-saving medications while somebody's asking us to raise the bed. People will talk to us and call us anesthesia. They don't even really know our name. So a lot of conversations going on in the operating room and we are essentially asked to determine was that directed toward me while we're doing so many things. So cognitive overload continues to be a significant factor. Production pressure somehow anesthesia has adopted this idea that we are there to serve others. Um namely the surgical team. I had a neuro chief of neurosurgery when I was just got out of school that said Suzanne slow down. what you're doing here is very important. And I and I think and I and I think about that every day because he's right. What we're doing is very important and we're often feel the pressure to serve others and leave our task kind of behind. Communication and teamwork. Many anesthesia providers are not formally trained uh to effectively communicate and to use effective teamwork principles. It's just not part of curricula in a formal way. Technology continues to advance. um that we're not a part of designing that makes things difficult. We don't really have ways to detect issues early before they grow larger. So, we all sometimes find ourselves with this massive um patient condition that we probably could have detected much earlier and kept it from growing larger. The distractions in the operating room are um are significant. music, conversations, poor communication, alarms. Sometimes we're asked to provide an anesthetic on a patient who is asleep and paralyzed. The lights are out and the music is very loud. So, these are two senses now that I don't have to try to detect things early to keep them from growing larger. Um, there are competing demands on our attention. And I'm going to add two more things. One is overconfidence. I think for some reason, haven't got to the heart of this yet, but ego plays a big role in um in some of the uh poor outcomes that we've seen. And we have a huge missed opportunity to learn from near misses. We have no one robust system where we can report something happened today so that somebody tomorrow could benefit from that. And I think we could close the gap on that. So those are just several that come to mind. >> Great. Thank you Suzanne and Naj. How Yeah. Any others to that's a lot. That's a long list. Any any comments on that? N any >> I I cannot agree more with Suzanne. But I will add also one more point. I think the job of nurses and anesthesiologists and nurse anesthesiology in operating group sometimes I think it's a little bit harder than airline pilots because uh we have this concept which was called uh cockpit resource management then it was changed to crew resource management CRM which was founded by again another late mentor Bob Hamri. like professor from University of Texas and CRM is becoming a national standard in United States is being regulated by FAA that governs the relationship between the cockpit crew make that is smoother because there have been many aviation accident that were attributed that these two players the first officer and captain they are not working together or there are some successes stories like Captain Sali Salenberger, Miracle and Hudson that he had a very good working relationship and they collaborated and they were able to land the US Airways which lost the trust because of the Canadian Geese that but when we and medicine or healthcare try to copy that they call it medical team management like crew resource management the same way that Suzanne mentioned about checklist. Checklist was in aviation but it has been used successfully in medicine. However, one of the principle of crew resource management is the person that we sitting on the left seat the captain he has been a right sitterter as a first officer. They are coming from the same background. However, that situation doesn't apply to the operating room. Surgeon is surgeon. Perfusionist is perfusionist and a sysiologist and a physiology nurse are there. They need to work together but they are not coming from the same background and they don't end replacing each other. See that's why that issue of communication and ease of communication the issue of power distance questioning attitude and the issue of pecking order is much more important to overcome in operating room than in a cockpit. That's why that's why as I said in my humble judgment this issue of human factors or what we call this macroeconomics are more important for anesthesiology nurses perusionist and surgeon in operating room than in the cockpit because of that similarity of the background. I think I'd like to I add one simple thing uh with with that n I really appreciate those comments because just one one small example you know W and Scliffe the organizationalformational theorists um that came out with this book called managing the unexpected it really drew me in because wouldn't we all like to manage something that we don't even know is going to happen and one of their principles is to defer to expertise and that does not mean defer to the person at the high highest hierarchical structure. It means that that expertise can change a time or two. So it it it it suggests that a physician might defer to a nurse at some point uh for example or that a nurse may defer to a orderly uh at some point. And that is something in healthcare that we for some reason highly resist. And sometimes the the expertise that we're deferring to is not really the person that should be um you know running a code or managing this critical event. So we do still struggle with those hierarchical structures even though we know how they can adversely impact uh patient outcomes. >> Yeah. I mean I think it's it it's fascinating what you're saying and and a lot of interventions in in human factors interventions in other industries are based on breaking down those hierarchies. So so I suppose the challenge and and uh you know to give our listeners some we we've we've talked about a lot of problems I suppose but human factors is about designing solutions. So, so how do we go about designing solutions for some of these challenges and you've outlaid outlined like a a lot of challenges there between you? Um so you know where where does human factors is that proactive design piece trying to design systems whereby we can break down hierarchies whereby we can give people you know opportunity to have the attention that they need to have when doing a task or opportunities to not you know to not um push the wrong button at the wrong time or so they they are all on varying levels of complexity in terms of designing those interventions but but just what you know have you got some examples from from anesthesia of what kind of practical solutions have been designed from a human factors perspective and how they've been implemented. So maybe um Naj have you you know have you seen examples or and then I'll go to Suzanne. I I I can refer to these industries that have been working with the again nuclear power and aviation. They have had some very good success in this. Basically what I say that sorry earlier we need both micro ergonomics work at the workstation level try to make sure that we are reducing all chances or potential for human error due to design induced error. Again always my my example is if you have two same shaped knob in the cockpit which was by the way one of the early work of aviation was that one of them control the landing gear the other one controlled the flaps and the pilot coming down for landing during the short final cannot take his eyes on the runway from the runway and was grabbing one pulling that And if it was not the flap and it was the landing gear, it was too late to deploy the landing gear and it crashed. This is to me is the best example of a design induced error that we have to fix it at the workstation level by shape coding by color coding and other things. But then above and beyond that we need to look at the organization and the work system design. This is my colleagueuh professor Pascar Karayan tried to do that with the healthcare industry at University of Wisconsin work system design for healthcare. It is basically it's not then necessarily the workstation is the job design is the relationship that people they have the the design of the feedback mechanism all of that but all of these sits on something which is called the foundation for all this improvement and that safety culture. If we don't have a conducive healthy safety culture, we cannot have a healthy communication free of uh harassment or respectful work environment or psychological safety with this called in the operating room. Yes, I vote for Nash to be CEO of the hospital system so that it can all trickle down from that that passion that we know is so true, but yet we struggle with and uh and I I agree with everything uh he said and believe it believe it in my heart that we still have that work to do. Uh from what I've surmised over the years, human factors gives us the tools, but culture determines whether we get to use them or not. And we have to have both. So, I look for ways, we were talking about, you know, how human factors has helped or could help. I look for ways um human factors can help a high-erforming specialty become even safer. Uh for instance, how can human factors help influencers model desired behavior? Because the person who's actually modeling the behavior matters. And I believe first of all, we have to teach them and reinforce human factors principles. And I don't think there's a lot of formal education uh in this area. How can human factors help create psychological safety? Well, by making safe behaviors the easiest, the be expected, and the consistently reinforced way of doing things. How can human factors help mitigate cognitive bias in anchoring and fixation? by the use of evidence-based algorithms, building situation awareness intentionally, instituting pauses at critical points in an anesthetic and surgery, and reducing perceptions of stress so that we can grow our cognitive capacity. You know, when safety culture is strong, safety wins over speed, curiosity wins over certainty, teamwork wins over hierarchy. Learning wins over blame. System improvement wins over, you know, individual perfection. And sharing near misses and bad outcomes wins over secrecy. You know, we change the culture one little step at a time. >> I think that's great, Suzanne. Yeah. I mean, it's it's just super sensible stuff, you know, that we need to keep working on. And um and it's not an easy path and it's a long it's a long road. Um and human factors isn't ever about quick fixes you know it's about those different layers as N says of the system and working at all those different layers. Um so I suppose just you know we've discussed some of the current you know challenges and the current situation in anesthesia and what has made anesthesia great in terms of safety and human factors and being a leader. I know we're not there yet. I'm hearing that from you. It's still a journey but um but just maybe before we we finish up like what what do you think are you know kind of new challenges or are new possibilities new good things and new challenges that are coming down the line like with artificial intelligence automation digital technologies and what role do you think human factors has to play in the in addressing those? I was I was interested to hear you say you know about technology coming at us without being designed by us you know as an example Suzanne so um maybe I'll hand over to you first just kind of what are those both the good side and the bad side of the things that are coming down the line. Yeah. So, I had the pleasure of watching a patient safety um movement foundation webinar recently on AI and one of the most um compelling um uh stories that came out was that electricity was designed you think about AI as electricity and electricity wasn't designed to make us safer but yet electricity does play a role in in safety. So the question simply isn't, you know, will AI work, but whether will AI help humans make better decisions under real clinical conditions, or will it just be more noise? Will it be more um data, but not necessarily more meaningful information. You know, throughout the history of anesthesia, our greatest safety advances haven't come from replacing clinicians. They've come from augmenting clinicians and clinicians work. uh pulse oxymmetry, for example, didn't replace vigilance. Capnography didn't replace clinical judgment. Checklists didn't replace expertise. They simply enhanced human performance. And I believe AI has the potential to become the next major major safety innovation. But we have to be obviously hold ourselves accountable and have a high degree of responsibility um as we use it. But imagine if an AI system that recognizes subtle physiological deterioration before it's obvious, predicts hypotension before the blood pressure falls or identifies patterns that suggest uh impending respiratory compromise. How much time that would give us to you know a heads up so that we could manage things um a little bit better. of all the cases that I've reviewed with really poor outcomes even today in 2025 and 2026 um I often think what if someone or something had recognized that the objective data no longer matched the team's mental model this outcome perhaps could have been quite different so I'm hoping that may be AI's greatest promise great and n what what is your feeling about AI I hope >> I guess Suzanne said everything but I just she used the keyword mental model and that's I think is a very important issue in both in nuclear and aviation. Uh the the human operator's mental model of a system and also the mental model that they have when the system goes from routine to non-rine and then when you are working in a team there is another concept which is called shared mental model. uh which touches upon situational awareness but is different theoretically and the issue of helping people to develop shared mental model particularly when they need to work as a team is extremely important. I just want to say one more thing because Suzan's comments and your good question Dr. Ward inspired me to bring it along. I'm not that familiar with anesthesiology work but I have observed that and I talked to Dr. L and other colleagues in department of anesthesiology at USC ke hospital. I think part of anesthesiology the work of anesthetic anesthesiologist and that that the issue of sequence is very important and order as Suzanne used that it's the takeoff cruise and landing that I'm going to quote you Suzanne from now forever that that was a very and during this course sequence is very important and out of sequence could cause some problem That reminds me of an example that I use here for aviation maintenance that I think is also very important for following the sequence and the error traps that could happen over there. I owe this to professor Jim Rezen. This is a a nut uh this is a bolt with eight knots over here. As you see there are eight knots over here. If the job is to disassemble that and putting that together as a maintenance related thing, there is only one way to disassemble that and this is to remove the first knot out then the second knot and the third knot. This is the sequence for disassembly. It's it's is governed by the design. I cannot take off this knot which is over here without taking this one and this one and this one and this one. However, when putting this back together, when you have that in a in a bucket, putting that back, there are eight factorial 40,000 ways that you can put this eight nuts together over there. But if there is only one the correct way if this is a special type of a washer this is a gasket that again in maintenance aviation maintenance is very important and think of that as a sequence that you need to do in anesthesiology there are many chances of error because of the design of that but if I could put numbers on this and then when you are I'm putting that back I Look at the numbers rather than the shape. See this is what we call that Q utilization. And for any job that the sequence is important and the sequence could have an impact on the final outcome on the success and and quality. We really need to get to this level of design. Try to look at that. This is what I call that interface level at the microeconomic level and at the same time we need to look at the macroeconomic level. Bring those hospital CEOs which I did that by the way in one case that I was a consultant. bring them together, put them in the operating room, ask them to observe or in the case of a major water utility, I took the CEOs to the what they call it tailgate meeting of the operators that they do maintenance at 5:00 a.m. They need to get a feel for the system, the system that they are running. And I want to open a parenthesis over here. I think the board of directors for medical centers for hospitals are more important than anybody else also because these people over here they can provide oversight on the operation. In the case of Boeing, there have been a major litigation. The Deliver court ruled that the board of directors of Boeing, they have had quote mission critical responsibility unquote and the safety. And if the board of director, they don't know what the hell is going on in the operation, you will have the two cases of going 737 and 346 people's dead. >> Yes. And I'm sorry we're coming to the end of of this great conversation and and what has struck me from it is just the the the breadth and the range of human factors um topics, possibilities, solutions, design options. Um so I suppose one last question for you both like this you know is there one key message for the anesthesia professional whether whether it's the nurse the anist you know whoever it is what is one key message you would like them to take away from today's discussion so Suzanne you first >> yeah I would like to say as many um presentations as I as I've given I feel like it's high price real estate people spend this money to come to conferences and you know you have them as a captive audience they should have something to take home to use tomorrow morning so that we can immediately start to improve the safety culture and I think overarching and I think it does fit into human factors here is to just be intentionally curious slow down during the critical moment question your assumptions pay attention to the objective data make sure it's still fitting your mental model and invite others to speak up and be willing to speak up yourself, but just slow down and uh we're not under the pressure that sometimes we think we are. Um and just begin to consider how these factors impact our performance. >> I think that's great advice. It's one of the key characteristics you mentioned one of the high reliability, you know, that constant vigilance, constant questioning for safety. So, I love that. Yes. N over to you. What is the key message you would like? Again, in addition to what two ladies said, you are referring to preoccupation with deviance or preoccupation with failure of the HRO which I cannot agree more with you. If you ask me for my last word, I would say that uh I said safety culture is really foundation for safety management system and everything else. And as I said in my letter in the economist about healthcare industry and that I think by I paraphrase that in that letter and I'm paraphrasing uh Peter Ducker for you which I put that in that letter. I think a culture eats a strategy, a structure and hierarchy for breakfast. Really safety culture I think is the foundation and it it's a strategy uh structure and hierarchy for breakfast. We have to start looking at that while looking at the workstation to learn lessons from this over here. Thank you. >> Great. Thank you. Thank you both so much. It's been a really it's been an absolute pleasure to to meet and listen to you both and um yeah, I'd just like to thank everybody for tuning in and listening. So, thank you so much to you both. Thank you to the um the two organizations that have hosted us, the American Association of Nurse Anesthesiology and the Patient Safety Movement Foundation. And we'll bring the webinar to a close there. And thank you all.