CT28 CREATING THE “ERROR ENVIRONMENT”

The Second Global Patient Challenge, ‘Safe Surgery Saves Lives’ initiative of the World Health Organisation (WHO) will promote standardised, evidence‐based approaches to improving patient safety, in part through measures to reduce certain common errors. From harmless slips (using salt instead of sugar) to disastrous and costly failures (a wrong drug leading to the death of a patient, wrong co‐ordinates in a navigational computer leading to the Erebus airline disaster, or the simultaneous use of empirical and metric systems of measurement in an international collaboration leading to the loss of a Mars probe), error shadows every human endeavour, in part because error is closely linked to creativity and success. Our team has developed realistic scenarios using a high‐fidelity human‐patient simulator, in which participants must cope with multiple demands at times of high stress and distraction. In this ‘error environment’ anaesthetists are likely to fail in various ways, which may be predicted from the fundamental theories of the genesis of human error, thus allowing us to better study these otherwise rare events. In the next phase of our research we plan to include surgeons as active subjects, and to focus on the functioning of the team rather than the individual. This will further elucidate the factors which contribute to positive and negative aspects of human performance and will inform intiatives (such as that of the WHO) to improve patient safety in the operating room.