First Reported Use of Team Cognitive Workload for Root Cause Analysis in Cardiac Surgery

Semin Thorac Cardiovasc Surg. 2019 Autumn;31(3):394-396. doi: 10.1053/j.semtcvs.2018.12.003. Epub 2018 Dec 19.

Abstract

Cognitive workload data of members of the cardiac surgery team can be measured intraoperatively and stored for later analysis. We present a case of a near-miss (medication error) that underwent root cause analysis using workload data. Heart rate variability data, representing workload levels, were collected from the attending surgeon, attending anesthesiologist, and lead perfusionist using wireless heart rate monitors. An episode of cognitive overload of the anesthesiologist due to a distractor was associated with the preventable error. Additional studies are needed to better understand the role of psychophysiological data in enhancing surgical patient safety.

Keywords: Cardiac surgery; Cognitive workload; Heart rate variability; Root cause analysis; Team workload.

MeSH terms

  • Administration, Intravenous
  • Anesthetists / psychology*
  • Clinical Competence
  • Cognition*
  • Coronary Artery Bypass / adverse effects*
  • Heart Rate
  • Heparin Antagonists / administration & dosage
  • Heparin Antagonists / adverse effects
  • Humans
  • Medication Errors / prevention & control*
  • Near Miss, Healthcare*
  • Patient Care Team*
  • Protamines / administration & dosage
  • Protamines / adverse effects
  • Risk Assessment
  • Risk Factors
  • Root Cause Analysis
  • Workload*

Substances

  • Heparin Antagonists
  • Protamines