Human error is increasingly recognized as a major cause of mishaps during anesthesia which result in patient injury. (1,2) Numerous strategies for reducing the likelihood of making an error have been proposed. Some examples of these strategies are: thorough preparation prior to anesthesia, development of meticulous work habits, and improved training procedures.(3) As long as humans provide anesthesia care, we will have the benefit of sensory and reasoning abilities unmatched by any machine, but also the potential for error. No amount of training and effort on the part of the individual can eliminate error completely. Decision support tools to aid the clinician therefore have great potential for helping to avoid accidents due to human error.

The aviation industry has utilized checklists for some time in an effort to reduce the contribution of human error to accidents. Pilots are required to use checklists for executing routine protocols to insure adequate preparation for each phase of flight. In addition, checklists are used for problem solving when incidents occur in flight so that important steps in addressing the problem are not overlooked. Indeed, the Federal Aviation Administration mandates the use of checklists in the cockpit. (4)

Checklists and Anesthesiology

The experience with checklists in anethesiology relates primarily to the pre-anesthesia equipment check. Studies evaluating the utility of this checklist have demonstrated a reduction in equipment-related incidents after adoption of a normal pre-anesthesia checklist.(5,6,7) . Chopra et al. recently published a description of their efforts to use the checklist paradigm to deal with errors in the operating room.(8)

An electronic checklist system has been developed which expands the checklist paradigm to include not only the pre-anesthesia checklist but also a number of additional protocols and problem solving checklists. The choice of checklists has been guided b the desire to: 1) prevent the occurrence of untoward incidents and 2) facilitate appropriate management of intraoperative problems. Errors made in managing problems are commonly due to fixation on a particular (wrong) diagnosis and omission of important steps in diagnosis or therapy. These errors are especially likely when faced with a rare event where the principles of management may not be immediately recalled. The checklist can serve in this instance as a memory aid and a mechanism for insuring that all possibilities are considered.

Electronic versus Paper

One of the frequently asked questions is whether there are clear advantages of an electronic checklist over a paper checklist. The paper checklist is typically constrained for convenience to a single sheet of 8.5 by 11 inch paper. For a single checklist, this paper format may be adequate, but the limitation of a single sheet of paper imposes constraints on the amount of information that can be included. The electronic checklist can provide more extensive checklists and support information in the form of on-line “help” to explain the checklist or provide insights for decision making. When multiple checklists are available, the paper approach becomes at best unwieldy and ultimately inadequate.

Electronic checklists may offer important medicolegal advantages in addition to decision support. Documentation that clinical care was appropriate is often difficult to provide during a malpractice proceeding. The handwritten record may be either illegible or an incomplete rendition of events. The use of an electronic checklist can be documented either in print or by an electronic record keeper. This type of documentation would leave little doubt that care was thorough and up to standard.

The electronic checklist system in use in our operating rooms has been implemented using the PC mode option of the SpaceLabs PC-2 monitor. This option allows for executing software developed by the user on the monitor including use of the touch screen. This option has been a useful tool since it eliminates the need to bring additional computer equipment into the operating room, and the user interface is consistent with that of the monitor.

The most extensive evaluation to date has been accomplished with the pre-anesthesia checklist. This checklist includes not only an anesthesia machine evaluation but also a check for all necessary life support equipment, e.g., resuscitator bag, laryngoscopes, endotracheal tubes and patient suction. The pre-anesthesia checklist is designed to help provide a thorough and efficient preparation for anesthesia. Each step flows logically to the next so that equipment need not be reconfigured many times for evaluation. The total time required to perform this checklist averages about five minutes.

Other protocol checklists developed to date include pre and post-induction checklists, an implementation of the relief protocol proposed by Cooper(9) and a review protocol designed to detect all preventable incidents. Problem-solving checklists focus on infrequent events (e.g., malignant hyperthermia, inspired C02) where memory support is likely to be most useful. Due to the infrequent nature of these anesthetic problems, it has been impossible to collect objective data about checklist utility in the operating room. Experience in aviation has shown that testing methods for preventing error must be done in the simulator environment where a greater number of usually low frequency events can occur. Fortunately, the development of anesthesia simulators makes these types of studies feasible.

Monitoring systems in the operating room have traditionally been used to present only monitored data to the anesthesiologist. These systems already have the potential to store large amounts of information for retrieval. Additional information is often useful to facilitate proper decision making in the operating room. (Every clinician will admit that a quick glance at the ACLS resuscitation algorithms provides a reassuring reminder of the important steps.) The trend toward networked anesthesia information management systems opens the potential to make large amounts of information readily accessible in the OR.

Studies Needed

Given the established, recognition that human error plays an important role in anesthesia incidents, methods to reduce such error must be developed. To date, there has been little if any change in anesthesia practice patterns to address this problem. The use of checklists is a familiar method that has been clearly shown in aviation to play an important role in preventing human error. Application of this approach to anesthesia is logical but studies are needed to ascertain the true utility of checklists for reducing human error.

Drs. Feldman and Blike and Mr. Cheung are from the Department of Anesthesiology, Yale University, New Haven, CT, and presented this material in a scientific exhibit at the 1991 ASA annual meeting.

References

1. Cooper J.B., Newbower R.S., Long C.D., McPeek B. Preventable anesthesia mishaps: A study of human factors. Anesthesiology 1978;49:399406

2. Gaba D.M.. Human Error in Anesthetic Mishaps. Intemational Anesthesiology Clinics 1989;27:137-147

3. Cooper J.B., Newbower R.S., Kitz R.J. An Analysis of Major Errors and Equipment Failures in Anesthesia Management: Considerations for Prevention and Detection. Anesthesiology 1984;60:34-42

4. Federal Aviation Regulation (FAR) 121.315

5. Charlton J.E. Checklists and Patient Safety (editorial), Anaesthesia 1990;45:425

6. Hunziker P., Koch J.P., Devitt J.H. Formalization and Implementation of an Institutional Preanesthetic Checklist. Canadian Journal of Anaesthesia 1990;37.S9

7. Kumar V., Barcellos W.A., Mehta M.P., Carter J.G. An analysis of critical incidents in a teaching department for quality assurance. A survey of mishaps during anaesthesia. Anaesthesia 1988;43:879

8. Chopra V., Bovill J.G., Spierdijk J. Checklists:

Aviation Shows the way to Safer Anesthesia. APSF Newsletter 1991;6(3):26

9. Cooper J.B., Newbower RS., Long C.D., Philip J.H. Critical incidents associated with intraoperative changes of anesthesia personnel. Anesthesiology 1982;56:4%-461