Noa Segall, PhD Awarded Anesthesia Patient Safety Foundation Grant

Noa Segall, PhD, Assistant Professor of Anesthesiology and Human Factors Engineer in the Human Simulation and Patient Safety Center, received a 2-year $149,999 Anesthesia Patient Safety Foundation award entitled “Forgetting to remember: Prospective memory error as an unexplored patient safety risk”.  This grant was designated as the APSF/ASA President’s Endowed Research Award.  Additionally, Dr. Segall’s proposal was awarded The Doctors Company Foundation Ann S. Lofsky, MD Research Award, which consists of an additional unrestricted amount of $5,000.

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. 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 will interview anesthesia providers in order to understand situations and conditions that are conducive to forgetting to perform clinical tasks. Interview questions will also probe task types that were more likely to be deferred or omitted and cueing strategies, i.e., methods for recalling tasks at the right time. We will analyze 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. The proposed work will have significant impact on our understanding of prospective memory as a source of errors in the operating room and will advance our ability to support clinicians’ cognitive work in this complex, busy environment.

Chris KeithNoa Segall, PhD Awarded Anesthesia Patient Safety Foundation Grant