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First Reported Use of Team Cognitive Workload for Root Cause Analysis in Cardiac Surgery
Marco A Zenati1, Kay B Leissner2, Suzana Zorca2
1Divison of Cardiac Surgery, Veterans Affairs Boston Healthcare System and Harvard Medical School, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Medical Robotics and Computer-Assisted Surgery (MRCAS) Laboratory, Boston, Massachusetts.
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.
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