The amount of information that anaesthesiologists are supposed to know during their daily practice is steadily growing. This information includes a thorough knowledge of various preoperative states; the dosage, interactions and side-effects of drugs; perioperative complications and their management; pain management; a variety of complex guidelines and protocols, including those that deal with the most acute emergencies, and much more. Due to the unique work environment of the anaesthesiologist, this information is often needed for real-time decision-making. We therefore have to ask ourselves whether it is possible to remember all this information, especially in times of stress and more importantly, can occasional inadequate knowledge contribute to medical errors committed by anaesthesiologists.
Other factors that may contribute to occasional inadequate knowledge of anaesthesiologists include the absence of formal monitoring of the status of knowledge of practising anaesthesia providers, shyness of active learning especially as one grows older, the provision of anaesthesia by personnel with inadequate knowledge and without adequate supervision due to cost and production pressures, and inadequate advance knowledge of patient's medical status due to the growth of same-day and office-based anaesthesia.
Anaesthesiologists have been known for their efforts to reduce medical errors in a systematic way . However, the exploration of what can be done further to reduce preventable patient harm in anaesthesia needs to continue incessantly . Our hypothesis is that a point-of-care information system may improve patient safety by preventing an occasional lack of information that may lead to medical errors during anaesthetic management. In this study, performed as a preliminary step in the development of a point-of-care information system by the European Society of Anaesthesiologists (ESA), we wanted to explore the attitudes of anaesthesiologists towards such a system.
A questionnaire was prepared by the authors with the help of the ESA's administrative staff and was validated in a pilot study including 25 anaesthesiologists. The questionnaires were included in the printed material distributed to all 2240 attendees of the ESA's annual meeting in Gothenburg, Sweden, which took place in April 2001. Collecting boxes for the questionnaires were located in different sites of the congress. The questions that were included in the questionnaire, as well as the answers, appear in the 'Results' section.
The questionnaire was answered by 329 anaesthesiologists (14.6% response rate). From the questionnaires, 324 were completed in full and in five questionnaires one question was not answered. The patient characteristics data of the anaesthesiologists answering the questionnaire are as follows:
• Age: 69% between 31 and 50, and 26% more than 50-yr old;
• Gender: 69% males and 31% females;
• Seniority: 79% qualified specialists and 16% residents; 68% with more than 10 yr of experience and 18% between 6 and 10 yr of experience;
• Location: 88% work in a hospital and 9% in a private clinic; 71% are from Western Europe, 19% from Eastern Europe and 7% from outside Europe.
Of all respondents, 85% considered themselves to be frequent Internet users, and 26% use an anaesthesia-automated record-keeper in their practice.
The following set of questions was aimed at elucidating the need for a point-of-care information system. The distribution of the answers (as percent of the respondents) appears after each question:
(a) If you need, in real time, additional medical information in the operating room, you most frequently use:
(i) Colleague or handbook - 68%
(ii) Electronic device - 21%
(iii) Memory and experience - 10%.
(b) While in the operating room, how often do you experience lack of knowledge about drugs, medical conditions and/or specific anaesthetic considerations?
(i) Once a day - 10%
(ii) Once a week - 36%
(iii) Once a month - 28%
(iv) Once a year - 10%
(v) Very rarely - 14%.
(c) When you do not know/remember some facts concerning drugs, medical conditions, etc. that are necessary for optimal management, you usually choose:
(i) A less optimal approach that you are more familiar with - 37%
(ii) The optimal approach anyway - 44%
(iii) Other - 16%.
(d) When encountering a sudden emergency situation (e.g. cardiac arrest, malignant hyperthermia, etc.), would you prefer to have written algorithms available on a screen in front of you?
(i) Yes - 63%
(ii) Not necessary - 36%.
(e) Do you feel that in the past you have committed medical errors during anaesthesia due to lack of medical information that can be found in a handbook?
(i) Yes - 39%
(ii) No - 34%
(iii) Don't know - 26%.
(f) If 'Yes', how often?
(i) No answer - 59%
(ii) Once a week - 3%
(iii) Once a month - 8%
(iv) Once every few months - 11%
(v) Very rarely - 19%.
(g) Do you think that having a source of medical information online in the operating room is:
(i) Not important - 7%
(ii) Important - 59%
(iii) Very important - 29%.
Twenty-five percent of responders would prefer to have the system in the monitor, 14% as part of an automated record-keeper, 38% as a separate device and 16% did not care. The preferred mode of navigation for the system was: touch screen - 47%; mouse - 19%; trim-knob - 10%. When asked how frequently the information in the system should be updated, 40% responded every 3 months and 49% responded once a year. The perceived value of adding such a system was: €100 - 12%; €500 - 23%; €1000 - 20%; €2000 or more - 18%.
When asked whether a point-of-care information system in the operating room should serve as an aid to decision-making or a source of additional learning, 76% of responders believed that it should serve as both. When asked whether such a system would not impair anaesthesiologists' vigilance in the operating room, 54% responded that it would not and 37% responded that it might. In a related question, 61% believed that reading in the operating room while administering anaesthesia should be allowed, and 29% thought that it should not. When asked whether the screen where the information is being displayed should go blank after a certain period of time, in order to make the anaesthesiologist examine the patient and his/her environment, 55% answered that it should and 39% thought that it should not. Of those who thought that the screen should go blank after a certain period of time, the majority chose 3-5 min as the 'on' time, with a wide variability as to the duration of the 'off' time (10 s to 5 min).
Patient safety has gained increased attention in recent years for a variety of reasons. Public perception of the healthcare professions has changed, and in many countries, iatrogenic injuries are now assumed (rightly or wrongly) to be the result of fault rather than bad luck. This is reflected in the enormous increase in civil and, in some countries, criminal litigation against hospitals and doctors which has resulted in a vast financial cost to the healthcare system. Concerns about safety and the cost of litigation have resulted in analysis of the causes of adverse events in an attempt to reduce their frequency and severity. The National Institute of Medicine report To err is human and other reports on medical errors [4,5] indicate that healthcare is not as safe as it should be. An important lesson learned from this emerging field of studies is that understanding the 'human factors' in healthcare is essential if a safer environment is to be created. 'Human factors' is defined as the study of the inter-relationships between human beings, the tools they use and their working environment .
Major accidents in medical practice are rarely caused by a single error. In common with other industries, healthcare organizations should recognize that absolute prevention of human error is impossible, and should therefore develop systems which minimize the risk of human error done by healthcare providers. More importantly than recognizing individual human error, we need to recognize and identify system failures that lead to individual errors . It is well recognized that most anaesthesia mishaps have a multi-factorial cause, in which human error plays a significant part [8,9]. According to one report analysing adverse events during anaesthesia , human error was the cause in 41%, equipment error in 50% and system error in 8.5% of incidents. According to another report , 65.9% of unplanned incidents during anaesthesia simulation were classified as human errors. In a prospective clinical study, lack of vigilance and failure to check were the most frequently reported types of human error during anaesthesia .
Inadequate knowledge as a possible source of errors during the administration of anaesthesia has not been thoroughly studied. According to one report, inadequate knowledge was considered to cause only 4% of anaesthesia-related complications . However, in view of the frequent errors in drugs administration  and the possible benefit of having written algorithm in the operating room , it is logical to assume that providing the necessary information at the point of care may improve patient safety. The results of our study suggest for the first time that inadequate knowledge may be a more important contributor than previously estimated. Among the responding anaesthesiologists (who by and large represent a population of senior, experienced, hospital-based and computer-literate professionals), 74% admitted to experience lack of medical knowledge at least once a month, and 46% admitted that it happened at least once a week. Moreover, the frequent choice of a less optimal but more familiar approach to patient management due to lack of knowledge should be a source of concern as well. However, the most significant findings of our study are the very high number of anaesthesiologists who admitted to having made frequent errors during anaesthesia due to lack of medical information that can be otherwise found in a handbook. Given the patient characteristics profile of the respondents (senior, experienced and hospital-based anaesthesiologists), it is not unreasonable to assume that a considerably greater number of errors are committed by less experienced anaesthesiologists in their daily practice. If the results of the survey are considered as representative of the actual frequency of errors, the following calculation indicates a real need for 'point-of-care' information. If each anaesthesiologist performs 70 procedures per month (a conservative estimate), then approximately 23 000 patients are treated each month by the 329 responders, of which 989 patients each month are subjected to a management error. If these data are extrapolated to all anaesthesiologists, then tens of thousands of patients are subjected to errors each month in Europe alone. This information is not surprising in view of the wide scope of ages, medical disorders, physiological data and medications that the anaesthesiologist encounters during everyday practice while working in the operating room, and the time pressure under which many decisions are being made.
Another aspect of the present survey was to assess anaesthesiologists' attitude to having a 'point-of-care' information system in the operating room. In view of the previous data it is not surprising that the vast majority of all responders believe that having such a system is either important or very important. Other high-risk professions, such as commercial airline pilots, have recognized the importance of the role of human factors in performance for decades and use point-of-care information systems for the performance of both routine and emergency procedures. Indeed the widespread use of electronic personal digital assistants by physicians has developed out of the necessity to have more information at the point of care. It is of course important to note that all sources of information at the point of care should be designed for quick, practical and user-friendly information retrieval, and the information itself should be validated, peer-reviewed and regularly updated.
The results of our study demonstrate that lack of knowledge by anaesthesiologists may be a 'system failure' that has been hitherto underestimated, and that providing the anaesthesiologist with an information system at the point of care may improve patient safety.
The authors would like to thank Mr Johan Popovich, Executive Director of the ESA, Ms Nathalie Caparat and the ESA office staff for their help in this project. The senior author of this work is the Chairman of the ESA's OLEH Sub-committee, and the Editor of the OLEH project. The Sheba Medical Centre is receiving an educational grant from the ESA for the production of the OLEH.
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