Human factors research in anesthesia patient safety: Techniques to elucidate factors affecting clinical task performance and decision making

Patient safety has become a major public concern. Human factors research in other high-risk fields has demonstrated how rigorous study of factors that affect job performance can lead to improved outcome and reduced errors after evidence-based redesign of tasks or systems. These techniques have increasingly been applied to the anesthesia work environment. This paper describes data obtained recently using task analysis and work-load assessment during actual patient care and the use of cognitive task analysis to study clinical decision making. A novel concept of "non-routine events" is introduced and pilot data are presented The results support the assertion that human factors research can make important contributions to patient safety. Information technologies play a key role in these efforts.