The Anesthesia Incident Reporting System (AIRS) was launched in 2011, turning 12 this year. We have thousands of reports letting us know when an anesthetic was associated with a complication. In reviewing the cases in AIRS, one theme we have noted is the persistence of distraction from electronic devices in the OR. AIRS, as the first specialty-specific reporting system in the United States, serves uniquely as a “canary in the coal mine,” giving us a signal when there are safety events affecting perioperative care.
Ten years ago, we identified this theme, and unfortunately this has not abated. As our astute readers are aware, about two years ago we looked at the case of air embolus with ERCP and noted this complication appeared to decrease over time with education and awareness. This month, we present the original case, and an updated conclusion, reflecting the increasing impact of electronic devices in our environment.
“Computer screen for new electronic anesthesia record froze. During the time of distraction while I was working on the problem, the patient blood pressure jumped 70mm Hg due to increased surgical stimulation, and I did not notice it immediately.”
“Due to focusing on new electronic anesthesia record, forgot to put ECG monitoring on patient before induction.”
On December 29, 1972, Eastern Air Line flight 401 was on final approach to Miami. As the crew prepared for landing, the light indicating that the forward landing gear had been appropriately lowered and locked did not illuminate. The cockpit crew aborted the landing, rose to 2,000 feet, and put the plane on autopilot. The captain and co-captain stayed in the cockpit to try to resolve the monitor problem, and the navigator was sent to visually inspect the landing gear. During this commotion, the autopilot was inadvertently disengaged and the plane began to slowly lose altitude. Despite (admittedly obtuse) warnings from air traffic control and the sounding of an audible cockpit alarm, the frustrated and distracted crew did not notice the loss of altitude until it was too late. The plane crashed into the Everglades at a speed of 227 mph, killing 101 of the 176 people on board. Investigation determined that the light bulb had simply burned out (asamonitor.pub/3A5RJ5a). There were many lessons learned from this accident; high among them is the extent to which distraction caused by malfunctioning technology can lead to adverse events.
The use of an anesthesia information management system (AIMS) has some clear advantages. It creates legible and consistently structured anesthesia records. It allows for real-time data capture and subsequent analysis. When combined with prompts or feedback, AIMS improves the timely administration of prophylactic antibiotics and perioperative beta blockers (Anesth Analg 2006;103:908-12; Jt Comm J Qual Patient Saf 2012;38:283-8). Finally, in theory, the automatic capture of vital signs and ventilation data should provide the anesthesia team more time and fewer distractions.
Of the 632 cases in AIRS, 16 explicitly use the word “distraction.” Seven of these are due to malfunctioning of an AIMS. In addition, six more incidents identify problems with AIMS that led to delays or other problems but did not indicate that the computer issue caused distraction. Thus, 13 of 632 (2.06%) of the cases in AIRS are related to problems with AIMS, and seven (1.11%) led to intraoperative distraction from patient care.
Distraction during anesthesia has become a growing topic in both the academic and lay press. Campbell et al. found that anesthesia clinicians were distracted from patient care or interrupted every three to five minutes. Forty-six of the 424 distractions identified (10.85%) were related to equipment (the authors did not specifically identify AIMS-related distraction) (Br J Anaesth 2012;109:707-15). Twenty-two percent of the distractions and 55% of the interruptions had a negative impact on patient care. In a similar study, Scavodelli et al. found an average of five distractions per case during induction of general anesthesia (range 1-14), for an average of one every 1.7 minutes. Forty and one-half percent were equipment-related (they did not specifically measure AIMS-related problems), and 82.8% had observable impact on patient care (Eur J Anaesthesiol 2010;27:683-9). While no link between these distractions and patient harm was made, other studies have linked surgical errors to disruptions in flow (Surgery 2007;142:658-65). It would be reasonable to assume that this is true in anesthesia as well.
The impact of AIMS on anesthesia clinicians' vigilance has received very little attention. While there is a compelling argument that not manually charting vital signs allows the anesthesia team to attend to more pressing patient care issues, the counter argument is that the need to manually chart creates greater vigilance. Davis et al. attempted to compare intraoperative vigilance between those with AIMS and those who used paper anesthesia charts (J Clin Monit Comput 2012;26:163-9). The authors asked anesthesia clinicians to report on 10 significant intraoperative parameters within 30 minutes of the end of the case. After collecting data from 214 cases, they were not able to detect a difference in the ability to recall these parameters. While AIMS have not been shown to be more distracting than standard anesthesia monitors, the cases of AIMS distraction in the AIRS database indicate that further study is required. The final issue related to the use of AIMS and anesthesia clinicians' vigilance relates to the accessibility of the computer. An AIMS requires a computer to run, and it should have access to at least the hospital-wide network so that patient data can be imported to the system. Most also allow at least limited access to the internet, e-mail, or other web-based sites. This, of course, opens up an assortment of potential distractions. Cell phones, PDAs, tablets, and other electronic devices further expand this problem. No data exist of the impact of these distractions on the performance of administering anesthesia, but extrapolation from data on operating a vehicle is sobering. Texting while driving lengthens the time it takes to stop a car nearly 20 times more than does being drunk (asamonitor.pub/3MLY39x).
AIMS are the future of anesthesia record-keeping, with penetration now approaching 25% of all practices. They offer advances in charting, decision support, data capture, and standardization of practice. As with any advance, we must be vigilant for the unintended consequences of AIMS, including unexpected breakdown, electronic failure, data capture errors, and other technologic “glitches.” This is evident in the two cases cited above and in about 2% of the cases in AIRS. The growing availability of computers in the OR also raises concerns about distraction due to texting, web surfing, answering e-mails, or even using the computer to legitimately look up patient-specific data. Until we fully understand the impact of these distractions on the care we provide, we can only listen to expert opinion, be aware of the potential hazards, share our experiences (e.g., report events to systems like AIRS), and make every effort to maintain vigilance in the care of our patients. Future solutions to intraoperative distraction will include more effective and intuitive alarm systems, more widespread use of checklists that promote attention to detail, and a better understanding of what distractions should be allowable during anesthesia care.
When this article was originally published, about 75% of anesthesiologists were charting on paper records, many of us were carrying flip phones or the occasional BlackBerry, and convenient internet access in ORs was far from ubiquitous. Pagers and wall phones were a common method of communication. Now, the situation has flipped. Almost all of us have a computer in our pocket with internet access, communication is moving quickly to digital applications, and electronic distractions have increased. A cursory review of the NACOR data shows approximately 70% of anesthetics are charted electronically.
In reviewing the AIRS database, distraction still encompasses approximately 2% of submitted reports. There is no indication this issue is improving. In fact, some of this distraction from electronic devices is completely avoidable. In 2014, an anesthesiologist was deposed as part of a malpractice claim and admitted to updating his Facebook page during a procedure that resulted in patient harm (asamonitor.pub/3ULBUu2). A review of closed claim data conducted by Domino et al. concluded that 91% of claims related to distraction were judged as substandard care versus 50% of other claims (Anesthesiology 2012;117:1156-8). The Anesthesia Patient Safety Foundation addressed these issues in February 2017 and, citing the Preferred Physicians Medical Risk Management Newsletter, recommended that anesthesia clinicians work within their facilities to establish guidelines and expectations for the entire OR team that balance the benefits of having access to personal electronic devices in the OR with the potential patient safety risks posed by the inappropriate use of these devices (asamonitor.pub/3UHfhXn).
The AIRS Committee offers a similar recommendation: Minimize the distractions of electronic devices by limiting usage to what is required to deliver the best possible patient care.
Each month, the AQI-AIRS Steering Committee abstracts a patient history submitted to AIRS and authors a discussion of the safety and human factors challenges involved. Absence of commentary should not be construed as agreement with the clinical decisions described. Reader feedback can be sent to firstname.lastname@example.org. Report incidents or download the AIRS mobile app at www.aqiairs.org.
This entry was written by Dr. Patrick Guffey on behalf of the AIRS Committee.