• Yasser A Sowb, Steven K Howard, Daniel B Raemer, David Feinstein, Kevin J Fish, and David M Gaba.
• Patient Simulation Center of Innovation (PSCI) and Anesthesiology Service, Veterans Affairs Palo Alto Health Care System, Stanford University School of Medicine, Stanford, California, USA. ysowb@yahoo.com
• Simul Healthc. 2006 Jan 1; 1 (1): 26-31.

Introduction: Anesthesiologists' cognitive resources such as their attention, knowledge, and strategies play an important role in the prevention and correction of critical events. In this paper, we examined anesthesiologists' responses to the anesthesia machine (AM) in the "off" position during a simulated emergent cesarean section scenario.Methods: All simulations were videotaped which allowed for offline review. At the beginning of the scenario, the AM system switch was purposefully turned to the off/standby position. The responses of 14 anesthesia residents at the Veterans Affairs Palo Alto Health Care System and Stanford University Simulation Center for Crisis Management Training in Health Care (VASC) and 11 anesthesia residents at the Boston Center for Medical Simulation (CMS) were analyzed.Results: Nine subjects at VASC restored the AM system switch to the "on" position on their own, whereas five subjects required help from another clinician. The median response time (RT) for all 14 subjects was 149.5 seconds. At CMS, five subjects restored the AM system switch to the "on" position on their own (median RT = 207 seconds), whereas two subjects received help from another anesthesia resident. There were four cases where the AM system switch problem was not corrected.Conclusions: Factors that could have contributed to subjects' difficulty in detecting and correcting the AM system switch included the unusual nature of the problem, the human factors design of the AM front panel and system switch, and inadequate training by the subjects. Improving the appearance of the AM's system switch and training of clinicians to recognize the location and functionality of the AM system switch could be useful in correcting such an event in a timely manner and reducing patient risk.

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