Cognitive modeling of intraoperative critical events

Abstract

Ventilation-related events (VREs) constitute a significant percentage of serious anesthesia mishaps. VREs occur as a result of mismatches between clinicians' resources and the cognitive demands during difficult situations. In this study, we used several cognitive task analysis (CTA) techniques to probe how clinicians think about respiratory function in order to investigate the cognitive challenges of assessing patient ventilation status. The results were used to build two models of the respiratory system that were used to map the cognitive demands imposed on clinicians during VRE. Results of the study were later used to guide the design of a simulator study to investigate clinicians' response to VRE and the role of current equipment in supporting clinical decision making. We describe the different CTA techniques used in our study and their usefulness in developing these models. We also present one of the models used in our study to illustrate our analysis and its results.