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Human Factors Research in Anesthesia Patient Safety

Techniques to Elucidate Factors Affecting Clinical Task Performance and Decision Making

Affiliations of the authors: Anesthesia Ergonomics Research Laboratory at the VA San Diego Medical Center, the San Diego Center for Patient Safety, and the Department of Anesthesiology, University of California, San Diego, La Jolla, California 92093.

Abstract

Patient safety has become a major public concern. Human factors research in other high-risk fields has demonstrated how rigorous study of factors that affect job performance can lead to improved outcome and reduced errors after evidence-based redesign of tasks or systems. These techniques have increasingly been applied to the anesthesia work environment. This paper describes data obtained recently using task analysis and workload assessment during actual patient care and the use of cognitive task analysis to study clinical decision making. A novel concept of "non-routine events" is introduced and pilot data are presented. The results support the assertion that human factors research can make important contributions to patient safety. Information technologies play a key role in these efforts.