Forgetting to Remember: Prospective Memory Error as an Unexplored Patient Safety Risk

Prospective memory is the human ability to remember to perform an intended action following some delay. Failures of prospective memory (PM) may be the most common form of human fallibility. They have been found to be a significant source of error in aviation and other work domains, but have received little attention in the anesthesia literature. Yet demanding perioperative work conditions, which often require multitasking and are fraught with interruptions and delays, place a heavy burden on the PM of anesthesia providers. For example, distractions – one source of PM errors – account for 6.5% of critical anesthesia incidents. There is a critical need to examine the effect of PM and its failures on patient safety and the care delivery process in the perioperative environment. The first objective of this project is to systematically quantify PM errors of anesthesia providers. An additional goal is to determine to what extent failures of PM contribute to medical errors in this domain.

We interviewed anesthesia providers in order to understand situations and conditions that are conducive to forgetting to perform clinical tasks. Interview questions also probed task types that were more likely to be deferred or omitted and cueing strategies, i.e., methods for recalling tasks at the right time. Interview participants were 19 nurse anesthetists, residents, fellows, and attending anesthesiologists. They provided varied examples of tasks that were delayed or omitted while preparing for surgery (e.g., bringing backup airway devices, checking a lab value, obtaining drugs from pharmacy, and administering antibiotics), during surgery (e.g., obtaining and checking on lab values, acting on abnormal lab values, labeling, reading, and administering drugs, closing off IV bags, and documenting care), and following surgery (e.g., wasting narcotic medications, signing out postoperative patients, and checking a chest x-ray of a patient with a central line). Interestingly, providers discussed a wide array of PM errors: only a few were reported by multiple providers. The factors contributing to forgetting (or deferring) tasks were varied, but time pressure was often cited and many lacked a cue to prompt task execution (e.g., recording urine output). A large majority of the events did not lead to patient harm.

We are currently analyzing interview transcripts to categorize PM failures along several axes, such as cue source (self-initiated or external), causes for task deferrals (disruptions, delays, etc.), and mechanisms for dealing with them. We will use these categories to guide observations and queries of anesthesia providers in the operating room in order to quantify and classify PM failures and distractions that may cause them. We will also analyze databases of anesthesia-related adverse events both retrospectively and prospectively to determine the extent to which PM errors and near misses affect patient safety in the perioperative environment.

PM errors can directly impact patient safety by causing providers to forget to execute tasks in the operating room, or to execute them too late. The proposed work will have significant impact on our understanding of PM as a source of errors in the perioperative environment and will advance our ability to support clinicians’ cognitive work in this complex, busy environment.

Reference

Segall N, Taekman JM, Wright MC. Forgetting to remember: Failures of prospective memory in anesthesia care. International Symposium of Human Factors and Ergonomics in Healthcare. 2014.

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