SAFETY CULTURE OF THE OPERATING ROOM ENVIRONMENT
Analyzing the Anesthetist's Domain: The Operational
World Versus the Organizational World
Psychologists and cognitive engineers who study real work environments
describe each field as a domain. Each domain has
specific characteristics that set it apart from others, including the nature of the
tasks to be performed, the relationships among the tasks, the time scale over which
they must be executed, and the criteria for their successful performance. This chapter
deals primarily with the operational domains in which anesthesia care is delivered,
primarily the OR, the PACU, and the ICU. However, as pointed out by Reason,[82]
[127]
[200]
[281]
[282]
as well as by Woods and Cook and colleagues,
[62]
[63]
[122]
[283]
what goes on in the operational domain is
extensively
shaped by the organizational and managerial environment in which it is located, even
to the point that operational personnel believe themselves to be the "victims" of
problematic decisions further back in the system.
In everyday practice, these distinctions are hidden or blurred.
The positive and negative contributions of the organizational and management elements
are often so embedded in the normal routine that they are difficult to isolate.
Interesting information about the system often comes from considering abnormal situations,
accidents, or near misses, instead of normal events. For example the investigation
of the loss of the space shuttle Columbia revealed a variety of latent errors within
the procedures and safety culture at NASA: "The accident was probably not an anomalous,
random event, but rather likely rooted in NASA's history and the space flight program's
culture."[284]
The report placed as much weight
on these factors as on the direct technical causes of the accident. Traditionally,
one speaks of errors arising in decisions and actions that led to a mishap. But
the term "error" is increasingly considered an inappropriate way to categorize behaviors
(being a judgment of attribution and blame) and should be thought of merely as a
way to identify behaviors at the locus of a critical situation. In this context
it must be understood that "errors are not the cause of an accident." Rather, errors
are usually the consequences of the combination of several underlying factors. Beyond
that, errors must combine with other circumstances to result in an accident or adverse
outcome[200]
[285]
This is illustrated in Figure 83-11
.
[286]
Figure 83-11
Model showing that errors are not the cause of accidents
[200]
: The "naïve view" that errors (E) are
the direct cause of an accident is incorrect. As shown in the "modern view," a combination
of underlying conditions (C1
, C2
, C3
) are the real
causes of an error. The error itself often requires further combination with contributing
factors (CF4
, C5
) to result in an accident. (Adapted
from Rall M, Manser T, Guggenberger H, Gaba DM, Unertl K: [Patient safety and errors
in medicine: Development, prevention and analyses of incidents.] Anästhesiologie,
Intensivmedizin, Notfallmedizin, Schmerztherapie 36:321–330, 2001, with permission.)
Some errors are actively produced in the operational domain, whereas
others are introduced by the organizational environment. James Reason, a psychologist
at the University of Manchester, England, described the latter using the concept
of "latent errors"[82]
[281]
:
... errors whose adverse consequences may lie dormant within the system for a long
time, only becoming evident when they combine with other factors to breach the system's
defenses. [They are] most likely to be spawned by those whose activities are removed
in both time and space from the direct control interface: designers, high-level decision
makers, construction workers, managers and maintenance personnel.
Latent errors probably exist in all complex systems, and Reason
adopted a medical metaphor to describe them as "resident pathogens." Like microorganisms
in the body, the resident pathogens remain under control until sets of local circumstances
"combine with these resident pathogens in subtle and often unlikely ways to thwart
the system's defenses and bring about its catastrophic breakdown"[82]
(see Fig. 83-13
). This
threat and error model was also well demonstrated by Helmreich at the University
of Texas ( Fig. 83-12
).[287]
