A Scare in the OR Highlights Value of Systems Engineering

Trying to Get Out of the Way Suddenly, the operating room (OR) anesthesiologist looks alarmed and confused. Our relaxed discussion from one second ago still hangs in the air. I’ve become invisible as he scrambles to understand what is happening with his patient. I don’t have answers—I’m a first-time visitor to an OR. His concern is contagious, and I instantly try to get myself out of the way. He barks a loud command for help, and three of the OR staff immediately stop their work and run over. I’ve jammed myself up against the wall to try to become small. Without looking at me, he shoves me to one side to make more room. Something bad is happening. A bank of four (eight total) infusion pumps has lit up with bright red alarm notices. The patient’s vital signs beat out overhead on a large-screen high-definition television (HDTV). I see each member of the OR team glancing up nervously as the patient’s blood pressure begins dropping. What am I doing here?! I’m 10 minutes into a scheduled 15-minute clinician-guided visit into an OR in which a patient is undergoing open-heart surgery. I am an invited outsider to this healthcare setting. My background includes 23 years’ experience in systems engineering research and development (R&D) for military command and control. The Association for the Advancement of Medical Instrumentation (AAMI) contacted me two years before and asked me to participate in steering discussions for alarm safety and systems engineering. I led advancements on these topics for the U.S. military, and AAMI wanted to leverage this, if possible, to help improve healthcare. A clinical lead (not related to my AAMI participation) has invited me to experience an OR setting for 15 minutes, so that I might understand the alarm safety and systems engineering challenges in this context. To prepare for this visit, I’ve changed into full OR garb (e.g., scrubs, hat, mask) for the first time. I’m nervous, but I’m pretending not to be because I’m grateful for the opportunity. Before entering the room, I started silently repeating to myself, “Don’t touch anything, don’t touch anything, don’t touch anything.”