Human reliability analysis of bronchoscope-assisted percutaneous dilatational tracheostomy: implications for simulation-based education

Aoife Lavelle,Mark J D Griffiths,Paul O'Connor,Mary White,Dara Byrne

doi:10.1186/s41077-020-00149-7

Abstract

BackgroundTeaching and assessing clinical procedures requires a clear delineation of the individual steps required to successfully complete the procedure. For decades, human reliability analysis (HRA) has been used to identify the steps required to complete technical procedures in higher risk industries. However, the use of HRA is uncommon in healthcare. HRA has great potential supporting simulation-based education (SBE) in two ways: (1) to support training through the identification of the steps required to complete a clinical procedure; and (2) to support assessment by providing a framework for evaluating performance of a clinical procedure. The goal of this study was to use HRA to identify the steps (and the risk associated with each of these steps) required to complete a bronchoscope-assisted percutaneous dilatational tracheostomy (BPDT). BPDT is a potentially high-risk minimally invasive procedure used to facilitate tracheostomy placement at the bedside or in the operating theatre.MethodsThe subgoals, or steps, required to complete the BPDT procedure were identified using hierarchical task analysis. The Systematic Human Error Reduction and Prediction Approach (SHERPA) was then used to identify potential human errors at each subgoal, the level of risk and how these potential errors could be prevented.ResultsThe BPDT procedure was broken down into 395 subgoals, of which 18% were determined to be of high-risk. The most commonly identified remediation strategies for reducing the risk of the procedure included: checklist implementation and audit, statutory and mandatory training modules, simulation training, consultant involvement in all procedures, and fostering a safety-focused hospital culture.ConclusionThis study provides an approach for how to systematically identify the steps required to complete a clinical procedure for both training and assessment. An understanding of these steps is the foundation of SBE. HRA can identify ‘a correct way’ for teaching learners how to complete a technical procedure, and support teachers to give systematic and structured feedback on performance.

Highlights

Critical care patients are among the most vulnerable patients in the hospital and, as such, are vulnerable to medical errors
Given the importance of identifying the steps in a procedure for both teaching and assessment, the aims of this study were to (1) use hierarchical task analysis (HTA) to provide a detailed examination of a high-risk critical care procedure— bronchoscope-assisted percutaneous dilatational tracheostomy (BPDT); (2) use Systematic Human Error Reduction and Prediction Approach (SHERPA) to identify those steps in the BPDT procedure that are vulnerable to human error; and (3) consider the utility of carrying out these types of analyses to support simulation-based education (SBE)
A summary HTA for the BPDT procedure is shown in Table 3, with the complete HTA provided in Supplemental Material 1

Summary

Introduction

Critical care patients are among the most vulnerable patients in the hospital and, as such, are vulnerable to medical errors. There is great potential for reducing human error in critical care settings. HRA techniques have great potential supporting simulationbased education (SBE) in two ways: (1) to support training through the identification of the steps required to compete a procedure; and (2) to support assessment by providing a framework for evaluating performance of a procedure. Human reliability analysis (HRA) has been used to identify the steps required to complete technical procedures in higher risk industries. HRA has great potential supporting simulation-based education (SBE) in two ways: (1) to support training through the identification of the steps required to complete a clinical procedure; and (2) to support assessment by providing a framework for evaluating performance of a clinical procedure. BPDT is a potentially high-risk minimally invasive procedure used to facilitate tracheostomy placement at the bedside or in the operating theatre

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Discussion

Conclusion