Production Pressure

The social and organizational environment may also act as a source of production pressure on anesthetists. Production pressure encompasses the economic and social pressures on workers to place production, not safety, as their primary priority.^[146] In anesthesiology, this typically means keeping the OR schedule moving speedily, with few cancellations and minimum time between cases. When anesthetists succumb to these pressures, they may skip appropriate preoperative evaluation and planning or they may fail to perform adequate pre-use checkout of equipment. Even when preoperative evaluation does take place, overt or covert pressure from surgeons (or others) can cause anesthetists to proceed with elective cases despite the existence of serious or uncontrolled medical problems. Production pressures can cause anesthetists to choose techniques that they otherwise believe to be inadvisable.

Gaba and associates^[135] reported on a randomized survey of California anesthesiologists concerning their experience with production pressures. They found that 49% of respondents had witnessed a situation in which patient safety was compromised by pressure on the anesthesiologist. Thirty percent reported strong to intense pressure from surgeons to proceed with a case they wished to cancel. Notably, 20% agreed with the statement that "If I cancel a case, I might jeopardize working with that surgeon at a later date."

Production pressure also leads to haste by the anesthetist, a psychologic precursor to the commission of unsafe acts. In the survey, 20% of respondents answered "sometimes" to the statement "I have altered my normal practices in order to speed the start of surgery," whereas 5% answered "often" to this statement. Twenty percent of respondents rated pressure by surgeons to hasten anesthetic preparation or induction as strong or intense. Repeated exposure to these conflicts can cause the anesthetist to internalize pressures; 38% of survey respondents felt strong to intense internal pressure to "get along" with surgeons, and 48% reported strong internal pressures to avoid delaying cases. Anesthetists may then feel impelled to go ahead with cases against their better judgment, even in the absence of overt pressure.

Investigating these aspects of the work environment is difficult because these relationships are driven by economic considerations as well as by the complex organizational and interpersonal networks linking the different medical cultures. Changing the environment will be equally challenging.