The Complacency Trap and Perfusionists Part 2 by Gary Grist RN CCP Emeritus
“Complacency is the lethal enemy of excellence.” Clark Gaither, MD, FAAP, Medical Director of the North Carolina Physicians Health Program.
Shaken from my complacency, I realized that I could not prevent all of the complications associated with the use of bubble oxygenators for CPB. Fortunately in,1991, we started using membrane oxygenators for CPB. The flexibility of these gave me the ability to do a variety of things that I could not do before with a bubbler. I could manipulate the sweep gas both as to oxygenation and carbon dioxide removal that I could not do before with a bubbler. I found that by sweep gas manipulation I could often stop and reverse the development of acidosis in a variety of situations instead of just treating it with buffer base (18,19). This improved the osmolarity as well. (Many years later when NIRS monitors came into use I was amazed at how manipulating the sweep gas changed the oxygenation and blood flow in the brain.) Ultrafiltrators became available about this time allowing me to remove excess fluid and manipulate the hematocrit at will without adding additional blood. Moreover the use of modified ultrafiltration (MUF) provided a powerful new tool to treat pulmonary hypertension that developed at weaning without adding fluid to the patient’s circulation. Starling’s law of the heart indicates that an increased filling pressure of the right heart results in increased cardiac output. But E.H. Starling probably never considered pulmonary hypertension and MUF as factors. The phenomenon of MUF astounded me because I could reduce the right heart pre-load, reverse the pulmonary hypertension and improve systemic blood pressure while removing fluid from the patient. There is no other situation in medicine that I know of where the right atrial pressure is reduced by removing circulating volume and results in an increase in systemic blood pressure. I have written about this phenomenon as well (20). Additionally, I also started to follow each patient for several days post-op. I wanted to know firsthand what complications they were having and if any of those complications could be related to the pump.
COMPLACENCY AND SAFETY
Throughout my early career I was a conscientious perfusionist and I thought that made me a “safe” perfusionist. But every time I sat behind the pump I was a little afraid that something might occur that I did not know how to handle. A little anxiety is a good thing because it sharpens the senses and heightens awareness. In my early years, I met over confident perfusionists at professional meetings who claimed that there was no situation that they could not handle, known or unknown. I wondered how they could be so certain of their abilities, particularly with an unknown situation. In hindsight, I realize that those perfusionists were caught in a ‘perfusion safety complacency trap’. Complacency is related to unsafe human performance more than anything else (1).
Once I recognized my own complacency and that of other perfusionists, I started to see it everywhere—-even in those designing our equipment. An engineer from one of the largest pump manufacturers once visited me to get my thoughts on the new pumps I had just purchased. It was a good pump but I told her it had several weaknesses. First, the touch screens were unprotected against someone dropping a med vial or clamp and shattering the screen. She wondered out loud; “Why would anyone deliberately drop something on a screen?” Apparently the company’s engineers never anticipated that an accident could shatter one of the delicate touch screens. (A few months later, the manufacturer replaced all the touch screens on this model due to a manufacturing defect and the company started offering an optional screen protection accessory. Why “optional” when the danger was clearly evident?) Then I noted that if a pump needed to be emergently changed out during a case, the power and communication connections were stiff and very difficult to manipulate. And the process of ‘recoding’ the replacement pump to operate once it was connected to the computerized instrument stack was time consuming in an emergency when timing was critical. (I had abandoned the in situ change out technique of a failed arterial pump in favor of a different remedy long before this but most other clinical programs and perfusion schools have not (2).) I also pointed out that there were no lifting handles on the individual roller pumps. This made it difficult to move the heavy roller pumps and more likely that one could be dropped and damaged during change out. It was my practice to annually rotate the roller pump with the least use time into the arterial slot position on the pump stand. The engineer reassured me that this was unnecessary because the pumps were so well engineered that… ”These pumps will never fail you!” She said this when I had just pointed out the potential for a touch screen failure minutes before. Eyeing the engineer I quietly wondered; “What was the last project you worked on…the Titanic?”
… AND THEN THE WHEELS FELL OFF
Then I pointed out to the engineer another problem with one of their older model pumps that I was using for both CPB and ECMO. The flat head machine screws that held the wheels on the pump stands were constantly coming loose and falling out. There was no sort of locking mechanism on them. We first noticed this while transporting an ECMO patient on to an elevator. One of the wheels came off the pump stand. The pump severely tipped and got stuck in the elevator door. I eventually got the pump balanced on three wheels and was able to move it and the patient with no further incident. On inspection of the three ECMO pumps and the two CPB pumps that I was using, all of them were missing one or more of the screws and the remaining screws were loose. I replaced the missing screws and tightened them all, thinking that I had solved the problem. But soon thereafter another pump lost a wheel and tipped precariously while in use. There was nothing in the IFU about this problem. So I put a screw driver on each pump and instructed my perfusion staff and ECMO Specialists to tighten the screws every day. (I should have made it a checklist item on that model pump.) I also kept a six foot 2X4 board in my pump room to use as a lever to lift the heavy pump stands to replace a wheel if one should fall off again. The engineer just rolled her eyes and said that nobody else had reported any difficulty. Rather than wait for an outside report the manufacturer should have asked the speculative question; with this design could a wheel fall off a pump while being moved to transport a patient? The manufacturer should have also asked if the system with “never fail” pumps failed, how could the perfusionist quickly, conveniently and safely mitigate the problem.
INCUMBENT ON PERFUSIONISTS, NOT ENGINEERS
These were good pumps that did a good job as long as everything functioned properly; essentially the ADAS of pumps. But it was clear that the designers never put much thought into what to do if everything did not function properly at a critical moment. It is incumbent on each perfusionist to imagine and anticipate equipment failures of all kinds before they occur and devise solutions to prevent injury to the patient. The same is true for disposable supplies. In the end, lives, careers and expensive litigation are at stake if this equipment fails and the problem cannot be quickly and safely mitigated. If new supplies, equipment or monitors make work easier and supposedly safer, be sure they do not also trigger an “Automation-Induced Complacency” trap.
PUMP INCIDENTS, PTSD AND OTR TRUCKERS
The longer I battled complacency, the more fronts opened in the ongoing war. Later in my career, after becoming a chief perfusionist, I was wary of leadership indifference. If the chief perfusionist does not care about battling complacency the staff perfusionists will not either. Fortunately, that was not my problem. Instead, after becoming a chief perfusionist, I became apprehensive for my perfusion staffers and the many ECMO specialists I was responsible to train and supervise. I did not want any patient injured or killed as a result of a pump incident. But equally so, I did not want any of my people to experience the angst that being responsible for the pump at the time of the incident can bring. I had seen post-traumatic stress disorder (PTSD) ruin careers of healthcare workers before (21). So I needed a way to prevent a perfusion safety complacency trap from developing among my staffers. I took inspiration from over-the-road (OTR) truck drivers, who have a constant battle with complacency. Working alone, they often pilot an 80,000 pound vehicle down a crowded and narrow highway at 70 mph, day and night and sometimes in horrid weather and where every bridge abutment is a potentially lethal obstacle and every other vehicle is an unpredictable wildcard. Every tedious hour of driving can sap the vigilance of a driver and allow complacency to sneak up. The safest drivers are those who are cognizant of the threat of complacency (22). To fight it they concentrate on identifying potential safety concerns and sharing their observations and experience with other drivers, often with citizens band (CB) radios. In other words, they communicate effectively.
EVOLUTION OF FMEA
I needed a way to identify potential safety concerns and share not only my observations and experience, but those of other perfusionists as well. Unfortunately CB radios are not available in hospitals and operating rooms. Incident reports, some of which are on line, can be useful. But they are root-cause-analysis tools and do not rank the risks of an incident nor do they anticipate various other potential incidents. Something was needed to break the perfusionists’ complacency traps. Then in 2004 Wehrli-Veit, Riley and Austin published their article on failure mode effects analysis (FMEA) for perfusionists (23). This is the perfect tool to fight complacency because it can 1) transmit observations and experience between perfusionists, 2) prevent incidents or mitigate those that occur, 3) anticipate consequences and future incidents and 4) rank the risks so that perfusionists can prioritize risk reduction activities. FMEAs are mandated by the 2001 Joint Commission Leadership Standard LD 5.2: “Support of Patient Safety and Medical/Health Care Error Reduction” with the goal of reducing the numbers of sentinel events and significant errors. This standard requires that hospitals and healthcare workers (and by implication perfusionists) 1) prevent adverse events and errors, rather than just react to them, 2) conduct proactive risk assessments, 3) recognize that a sentinel event root cause analysis is reactive and will not meet the standard’s compliance on its own and 4) provide a “failure mode analysis” for proactive process review. In other words Standard LD 5.2 prohibits complacency in healthcare. To this end, after retirement, I began a national project through AmSECT to improve the safety consciousness of the perfusion community using FMEAs (24).
That is the story of my fight against complacency. One need not discover a new perfusion perspective like OPFT to combat complacency. Just maintain an open mind and incorporate the following components:
1) Do not be satisfied with the status quo. Advanced perfusion techniques or research does not have to be involved. Instead, talk frequently with other perfusionists and visit other programs to see how they are doing everyday chores. Adjusting a simple, overlooked thing might greatly improve the safety of a program.
2) Perform routine safety training frequently. Do not consider this a waste of time if an incident never occurs. There is no way to track incidents that do not occur as a result of safety training.
3) Practice constant vigilance. In legal terms this is “due diligence” which by definition is a common sense effort to intercept potential problems before they occur.