Academic Appointments

Administrative Appointments

  • Associate Dean for Immersive and Simulation-based Learning, Stanford University School of Medicine (2004 - Present)

Honors & Awards

  • Dr. Larry Zaroff Man of Good Conscience Award (for promoting the careers of women in medicine), American Medical Women’s Association (April, 2017)
  • Pioneer in Simulation Award, Society for Simulation in Healthcare (January, 2017)
  • Bernard H. Eliasberg Award, Icahn School of Medicine at Mount Sinai (April, 2015)
  • Under Secretary for Health Award for Excellence in Clinical Simulation Training, Education & Rsch, United States Department of Veterans Affairs (January, 2011)
  • David M. Worthen Award, United States Department of Veterans Affairs (2003)
  • Kaiser Award for Outstanding Innovative Contribution to Medical Education, Stanford School of Medicine (2010)
  • J.S. Gravenstein Award for Lifetime Achievement, Society for Technology in Anesthesia (January, 2011)
  • IARS Teaching Achievement Award, International Anesthesia Research Society (2007)
  • SEA/Duke Award for Innovation in Anesthesia Education, Society for Education in Anesthesia (October, 2003)

Boards, Advisory Committees, Professional Organizations

  • Founding Editor-in-Chief, Simulation in Healthcare, Society for Simulation in Healthcare (2016 - Present)
  • Editor-in-Chief, Simulation in Healthcare, Society for Simulation in Healthcare (2004 - 2016)
  • Board of Directors, Society for Simulation in Healthcare (2003 - 2016)
  • Board of Directors and Executive Committee, Anesthesia Patient Safety Foundation (1990 - Present)
  • Simulation Education Task Force/Committee/Editorial Board, American Society of Anesthesiologists (2004 - Present)
  • Founding Board Member, Emergency Manuals Implementation Collaborative (2013 - Present)

Professional Education

  • MD, Yale School of Medicine, Medicine (1980)
  • BS Engg, Northwestern University, Biomedical Engineering (1976)

Research & Scholarship

Current Research and Scholarly Interests

Improving patient safety through a variety of means, including applying theories of organizational safety to health care; developing and testing the application of immersive and simulation-based techniques for education, training, performance assessment, and research, measuring and intervening in hospital safety cultures


2017-18 Courses

Graduate and Fellowship Programs


All Publications

  • A Taxonomy of Delivery and Documentation Deviations During Delivery of High-Fidelity Simulations SIMULATION IN HEALTHCARE-JOURNAL OF THE SOCIETY FOR SIMULATION IN HEALTHCARE McIvor, W. R., Banerjee, A., Boulet, J. R., Bekhuis, T., Tseytlin, E., Torsher, L., DeMaria, S., Rask, J. P., Shotwell, M. S., Burden, A., Cooper, J. B., Gaba, D. M., Levine, A., Park, C., Sinz, E., Steadman, R. H., Weinger, M. B. 2017; 12 (1): 1-8


    We developed a taxonomy of simulation delivery and documentation deviations noted during a multicenter, high-fidelity simulation trial that was conducted to assess practicing physicians' performance. Eight simulation centers sought to implement standardized scenarios over 2 years. Rules, guidelines, and detailed scenario scripts were established to facilitate reproducible scenario delivery; however, pilot trials revealed deviations from those rubrics. A taxonomy with hierarchically arranged terms that define a lack of standardization of simulation scenario delivery was then created to aid educators and researchers in assessing and describing their ability to reproducibly conduct simulations.Thirty-six types of delivery or documentation deviations were identified from the scenario scripts and study rules. Using a Delphi technique and open card sorting, simulation experts formulated a taxonomy of high-fidelity simulation execution and documentation deviations. The taxonomy was iteratively refined and then tested by 2 investigators not involved with its development.The taxonomy has 2 main classes, simulation center deviation and participant deviation, which are further subdivided into as many as 6 subclasses. Inter-rater classification agreement using the taxonomy was 74% or greater for each of the 7 levels of its hierarchy. Cohen kappa calculations confirmed substantial agreement beyond that expected by chance. All deviations were classified within the taxonomy.This is a useful taxonomy that standardizes terms for simulation delivery and documentation deviations, facilitates quality assurance in scenario delivery, and enables quantification of the impact of deviations upon simulation-based performance assessment.

    View details for DOI 10.1097/SIH.0000000000000184

    View details for Web of Science ID 000393947700001

    View details for PubMedID 28146449

  • Simulation-based Assessment of the Management of Critical Events by Board-certified Anesthesiologists. Anesthesiology Weinger, M. B., Banerjee, A., Burden, A. R., McIvor, W. R., Boulet, J., Cooper, J. B., Steadman, R., Shotwell, M. S., Slagle, J. M., DeMaria, S., Torsher, L., Sinz, E., Levine, A. I., Rask, J., Davis, F., Park, C., Gaba, D. M. 2017


    We sought to determine whether mannequin-based simulation can reliably characterize how board-certified anesthesiologists manage simulated medical emergencies. Our primary focus was to identify gaps in performance and to establish psychometric properties of the assessment methods.A total of 263 consenting board-certified anesthesiologists participating in existing simulation-based maintenance of certification courses at one of eight simulation centers were video recorded performing simulated emergency scenarios. Each participated in two 20-min, standardized, high-fidelity simulated medical crisis scenarios, once each as primary anesthesiologist and first responder. Via a Delphi technique, an independent panel of expert anesthesiologists identified critical performance elements for each scenario. Trained, blinded anesthesiologists rated video recordings using standardized rating tools. Measures included the percentage of critical performance elements observed and holistic (one to nine ordinal scale) ratings of participant's technical and nontechnical performance. Raters also judged whether the performance was at a level expected of a board-certified anesthesiologist.Rater reliability for most measures was good. In 284 simulated emergencies, participants were rated as successfully completing 81% (interquartile range, 75 to 90%) of the critical performance elements. The median rating of both technical and nontechnical holistic performance was five, distributed across the nine-point scale. Approximately one-quarter of participants received low holistic ratings (i.e., three or less). Higher-rated performances were associated with younger age but not with previous simulation experience or other individual characteristics. Calling for help was associated with better individual and team performance.Standardized simulation-based assessment identified performance gaps informing opportunities for improvement. If a substantial proportion of experienced anesthesiologists struggle with managing medical emergencies, continuing medical education activities should be reevaluated.

    View details for DOI 10.1097/ALN.0000000000001739

    View details for PubMedID 28671903

  • A Joint Leap into a Future of High-Quality Simulation Research-Standardizing the Reporting of Simulation Science. Simulation in healthcare Sevdalis, N., Nestel, D., Kardong-Edgren, S., Gaba, D. M. 2016; 11 (4): 236-237

    View details for DOI 10.1097/SIH.0000000000000179

    View details for PubMedID 27501222

  • Comparative-Effectiveness of Simulation-Based Deliberate Practice Versus Self-Guided Practice on Resident Anesthesiologists' Acquisition of Ultrasound-Guided Regional Anesthesia Skills. Regional anesthesia and pain medicine Udani, A. D., Harrison, T. K., Mariano, E. R., Derby, R., Kan, J., Ganaway, T., Shum, C., Gaba, D. M., Tanaka, P., Kou, A., Howard, S. K. 2016; 41 (2): 151-157


    Simulation-based education strategies to teach regional anesthesia have been described, but their efficacy largely has been assumed. We designed this study to determine whether residents trained using the simulation-based strategy of deliberate practice show greater improvement of ultrasound-guided regional anesthesia (UGRA) skills than residents trained using self-guided practice in simulation.Anesthesiology residents new to UGRA were randomized to participate in either simulation-based deliberate practice (intervention) or self-guided practice (control). Participants were recorded and assessed while performing simulated peripheral nerve blocks at baseline, immediately after the experimental condition, and 3 months after enrollment. Subject performance was scored from video by 2 blinded reviewers using a composite tool. The amount of time each participant spent in deliberate or self-guided practice was recorded.Twenty-eight participants completed the study. Both groups showed within-group improvement from baseline scores immediately after the curriculum and 3 months following study enrollment. There was no difference between groups in changed composite scores immediately after the curriculum (P = 0.461) and 3 months following study enrollment (P = 0.927) from baseline. The average time in minutes that subjects spent in simulation practice was 6.8 minutes for the control group compared with 48.5 minutes for the intervention group (P < 0.001).In this comparative effectiveness study, there was no difference in acquisition and retention of skills in UGRA for novice residents taught by either simulation-based deliberate practice or self-guided practice. Both methods increased skill from baseline; however, self-guided practice required less time and faculty resources.

    View details for DOI 10.1097/AAP.0000000000000361

    View details for PubMedID 26866296

  • Evaluating the Impact of Classroom Education on the Management of Septic Shock Using Human Patient Simulation. Simulation in healthcare Lighthall, G. K., Bahmani, D., Gaba, D. 2016; 11 (1): 19-24


    Classroom lectures are the mainstay of imparting knowledge in a structured manner and have the additional goals of stimulating critical thinking, lifelong learning, and improvements in patient care. The impact of lectures on patient care is difficult to examine in critical care because of the heterogeneity in patient conditions and personnel as well as confounders such as time pressure, interruptions, fatigue, and nonstandardized observation methods.The critical care environment was recreated in a simulation laboratory using a high-fidelity mannequin simulator, where a mannequin simulator with a standardized script for septic shock was presented to trainees. The reproducibility of this patient and associated conditions allowed the evaluation of "clinical performance" in the management of septic shock. In a previous study, we developed and validated tools for the quantitative analysis of house staff managing septic shock simulations. In the present analysis, we examined whether measures of clinical performance were improved in those cases where a lecture on the management of shock preceded a simulated exercise on the management of septic shock. The administration of the septic shock simulations allowed for performance measurements to be calculated for both medical interns and for subsequent management by a larger resident-led team.The analysis revealed that receiving a lecture on shock before managing a simulated patient with septic shock did not produce scores higher than for those who did not receive the previous lecture. This result was similar for both interns managing the patient and for subsequent management by a resident-led team.We failed to find an immediate impact on clinical performance in simulations of septic shock after a lecture on the management of this syndrome. Lectures are likely not a reliable sole method for improving clinical performance in the management of complex disease processes.

    View details for DOI 10.1097/SIH.0000000000000126

    View details for PubMedID 26836464

  • Evaluation of a Standardized Program for Training Practicing Anesthesiologists in Ultrasound-Guided Regional Anesthesia Skills. Journal of ultrasound in medicine Mariano, E. R., Harrison, T. K., Kim, T. E., Kan, J., Shum, C., Gaba, D. M., Ganaway, T., Kou, A., Udani, A. D., Howard, S. K. 2015; 34 (10): 1883-1893


    Practicing anesthesiologists have generally not received formal training in ultrasound-guided perineural catheter insertion. We designed this study to determine the efficacy of a standardized teaching program in this population.Anesthesiologists in practice for 10 years or more were recruited and enrolled to participate in a 1-day program: lectures and live-model ultrasound scanning (morning) and faculty-led iterative practice and mannequin-based simulation (afternoon). Participants were assessed and recorded while performing ultrasound-guided perineural catheter insertion at baseline, at midday (interval), and after the program (final). Videos were scored by 2 blinded reviewers using a composite tool and global rating scale. Participants were surveyed every 3 months for 1 year to report the number of procedures, efficacy of teaching methods, and implementation obstacles.Thirty-two participants were enrolled and completed the program; 31 of 32 (97%) completed the 1-year follow-up. Final scores [median (10th-90th percentiles)] were 21.5 (14.5-28.0) of 30 points compared to 14.0 (9.0-20.0) at interval (P < .001 versus final) and 12.0 (8.5-17.5) at baseline (P < .001 versus final), with no difference between interval and baseline. The global rating scale showed an identical pattern. Twelve of 26 participants without previous experience performed at least 1 perineural catheter insertion after training (P < .001). However, there were no differences in the monthly average number of procedures or complications after the course when compared to baseline.Practicing anesthesiologists without previous training in ultrasound-guided regional anesthesia can acquire perineural catheter insertion skills after a 1-day standardized course, but changing clinical practice remains a challenge.

    View details for DOI 10.7863/ultra.14.12035

    View details for PubMedID 26384608

  • Practice Improvements Based on Participation in Simulation for the Maintenance of Certification in Anesthesiology Program ANESTHESIOLOGY Steadman, R. H., Burden, A. R., Huang, Y. M., Gaba, D. M., Cooper, J. B. 2015; 122 (5): 1154-1169


    This study describes anesthesiologists' practice improvements undertaken during the first 3 yr of simulation activities for the Maintenance of Certification in Anesthesiology Program.A stratified sampling of 3 yr (2010-2012) of participants' practice improvement plans was coded, categorized, and analyzed.Using the sampling scheme, 634 of 1,275 participants in Maintenance of Certification in Anesthesiology Program simulation courses were evaluated from the following practice settings: 41% (262) academic, 54% (339) community, and 5% (33) military/other. A total of 1,982 plans were analyzed for completion, target audience, and topic. On follow-up, 79% (1,558) were fully completed, 16% (310) were partially completed, and 6% (114) were not completed within the 90-day reporting period. Plans targeted the reporting individual (89% of plans) and others (78% of plans): anesthesia providers (50%), non-anesthesia physicians (16%), and non-anesthesia non-physician providers (26%). From the plans, 2,453 improvements were categorized as work environment or systems changes (33% of improvements), teamwork skills (30%), personal knowledge (29%), handoff (4%), procedural skills (3%), or patient communication (1%). The median word count was 63 (interquartile range, 30 to 126) for each participant's combined plans and 147 (interquartile range, 52 to 257) for improvement follow-up reports.After making a commitment to change, 94% of anesthesiologists participating in a Maintenance of Certification in Anesthesiology Program simulation course successfully implemented some or all of their planned practice improvements. This compares favorably to rates in other studies. Simulation experiences stimulate active learning and motivate personal and collaborative practice improvement changes. Further evaluation will assess the impact of the improvements and further refine the program.

    View details for DOI 10.1097/ALN.0000000000000613

    View details for Web of Science ID 000354088500025

    View details for PubMedID 25985025

  • This Is Not a Test! Misconceptions Surrounding the Maintenance of Certification in Anesthesiology Simulation Course ANESTHESIOLOGY Weinger, M. B., Burden, A. R., Steadman, R. H., Gaba, D. M. 2014; 121 (3): 655-659
  • Human factors engineering in patient safety. Anesthesiology Weinger, M. B., Gaba, D. M. 2014; 120 (4): 801-806

    View details for DOI 10.1097/ALN.0000000000000144

    View details for PubMedID 24481419

  • Towards meaningful simulation-based learning with medical students and junior physicians MEDICAL TEACHER Keskitalo, T., Ruokamo, H., Gaba, D. 2014; 36 (3): 230-239


    This research provides an educational perspective on simulation-based medical education by implementing both the characteristics of meaningful learning and the concepts of facilitating, training, and learning processes.This study aims to evaluate, from the perspectives of both facilitators and students, the meaningfulness of five different simulation-based courses.The courses were implemented in the spring of 2010. The data were collected from facilitators (n = 9) and students (n = 25) using group interviews (one individual interview), observations, video recordings, and pre- and post-questionnaires. The research analyzes qualitative data using the qualitative content analysis method to answer the following research question: From facilitators' and students' perspectives, how does the facilitating and training in simulation-based learning environments (SBLEs) foster the meaningful learning of students?It seems that simulation-based learning is, at its foundation, meaningful since it inherently supports the many characteristics of meaningful learning. However, characteristics also exist that simulation-based learning does not inherently support. In this study, the goal-oriented, self-directed, and individual training characteristics were only somewhat supported during the facilitation and training in SBLEs.In running these courses in the future, facilitators should concentrate on those characteristics that were only somewhat supported.

    View details for DOI 10.3109/0142159X.2013.853116

    View details for Web of Science ID 000333176300007

    View details for PubMedID 24261916

  • Perioperative Cognitive Aids in Anesthesia: What, Who, How, and Why Bother? ANESTHESIA AND ANALGESIA Gaba, D. M. 2013; 117 (5): 1033-1036

    View details for DOI 10.1213/ANE.0b013e3182a571e3

    View details for Web of Science ID 000330435700001

    View details for PubMedID 24149497

  • Improving patient care through leadership engagement with frontline staff: a Department of Veterans Affairs case study. Joint Commission journal on quality and patient safety / Joint Commission Resources Singer, S. J., Rivard, P. E., Hayes, J. E., Shokeen, P., Gaba, D., Rosen, A. 2013; 39 (8): 349-360


    Leveraging Frontline Expertise (LFLE) is a patient safety intervention for engaging senior managers with the work-systems challenges faced by frontline workers and ensuring follow-up and accountability for systemic change. A study was conducted to assess the ability to refine, implement, and demonstrate the effectiveness of LFLE, which was designed for and tested in private-sector hospitals, in a Department of Veterans Affairs medical center (VAMC), typically a more hierarchical setting.LFLE was pilot tested in an urban, East coast-based VAMC, which implemented LFLE in its emergency department and operating room, with the medical/surgical ward and ICU serving as controls. A 20-month multimethod evaluation involved interviews, observation, data-tracking forms, and surveys to measure participant perceptions of the program, operational benchmarks of effectiveness, and longitudinal change in safety climate.Implementation showed fidelity to program design. Participating units identified 22 improvement opportunities, 16 (73%) of which were fully or partially resolved. Senior managers' attitudes toward LFLE were more positive than those of frontline staff, whose attitudes were mixed. Perceptions of safety climate deteriorated during the study period in the implementation units relative to controls.LFLE can be implemented in the VA, yield work-system improvements, and increase alignment of improvement aims and actions across hierarchical levels. Yet the results also warn against dangers inherent in adapting improvement programs to new settings. Findings suggest the need for active listening and learning from frontline staff by senior managers and trust building across hierarchical

    View details for PubMedID 23991508

  • Perspective: thorniest issues in healthcare. Biomedical instrumentation & technology / Association for the Advancement of Medical Instrumentation Gaba, D. M. 2013; 47 (4): 299-303

    View details for DOI 10.2345/0899-8205-47.4.299

    View details for PubMedID 23919786

  • Simulations That Are Challenging to the Psyche of Participants How Much Should We Worry and About What? SIMULATION IN HEALTHCARE-JOURNAL OF THE SOCIETY FOR SIMULATION IN HEALTHCARE Gaba, D. M. 2013; 8 (1): 4-7

    View details for DOI 10.1097/SIH.0b013e3182845a6f

    View details for Web of Science ID 000314807500002

    View details for PubMedID 23380693

  • Healthcare facilitators' and students' conceptions of teaching and learning - An international case study INTERNATIONAL JOURNAL OF EDUCATIONAL RESEARCH Keskitalo, T., Ruokamo, H., Vaisanen, O., Gaba, D. 2013; 62: 175-186
  • Preliminary Study of Ergonomic Behavior During Simulated Ultrasound-Guided Regional Anesthesia Using a Head-Mounted Display JOURNAL OF ULTRASOUND IN MEDICINE Udani, A. D., Harrison, T. K., Howard, S. K., Kim, T. E., Brock-Utne, J. G., Gaba, D. M., Mariano, E. R. 2012; 31 (8): 1277-1280


    A head-mounted display provides continuous real-time imaging within the practitioner's visual field. We evaluated the feasibility of using head-mounted display technology to improve ergonomics in ultrasound-guided regional anesthesia in a simulated environment. Two anesthesiologists performed an equal number of ultrasound-guided popliteal-sciatic nerve blocks using the head-mounted display on a porcine hindquarter, and an independent observer assessed each practitioner's ergonomics (eg, head turning, arching, eye movements, and needle manipulation) and the overall block quality based on the injectate spread around the target nerve for each procedure. Both practitioners performed their procedures without directly viewing the ultrasound monitor, and neither practitioner showed poor ergonomic behavior. Head-mounted display technology may offer potential advantages during ultrasound-guided regional anesthesia.

    View details for Web of Science ID 000306985100017

    View details for PubMedID 22837293

  • External Validation of Simulation-Based Assessments With Other Performance Measures of Third-Year Anesthesiology Residents SIMULATION IN HEALTHCARE Mudumbai, S. C., Gaba, D. M., Boulet, J. R., Howard, S. K., Davies, M. F. 2012; 7 (2): 73-80


    There has been interest in the use of high-fidelity medical simulation to evaluate performance. We hypothesized that technical and nontechnical performance in the simulated environment is related to other various criterion measures, providing evidence to support the validity of the scores from the performance-based assessment.Twelve third-year anesthesia residents participated in a series of 6 short 5-minute scenarios and 1 longer 30-minute scenario. The short scenarios measured technical skills, whereas the longer one focused on nontechnical skills. Two independent raters scored subjects using analytic and holistic ratings. Short scenarios involved acute hemorrhage, blocked endotracheal tube, bronchospasm, hyperkalemia, tension pneumothorax, and unstable ventricular tachycardia. The long scenario concerned management of myocardial ischemia/infarction leading to cardiac arrest. Scores from the simulations were correlated with (a) rankings generated from an Internet-based global ranking instrument that categorized residents based on overall clinical ability and (b) residency board scores.There were moderate correlations between various participant scores from the simulation-based assessment and aggregate rankings based on the global ranking instrument and residency examination scores.The associations between simulator performance, both for technical and nontechnical skills, and other markers of ability provide some evidence to support the validity of simulation-based assessment scores. Replication studies with larger numbers of residents are warranted.

    View details for DOI 10.1097/SIH.0b013e31823d018a

    View details for Web of Science ID 000302776800001

    View details for PubMedID 22374230

  • Adapting Space Science Methods for Describing and Planning Research in Simulation in Healthcare Science Traceability and Decadal Surveys SIMULATION IN HEALTHCARE-JOURNAL OF THE SOCIETY FOR SIMULATION IN HEALTHCARE Gaba, D. M. 2012; 7 (1): 27-31


    Two recent conferences have reviewed the state of research on simulation in healthcare and considered future directions. They both point to the need for more comprehensive and robust studies on a variety of aspects of simulation. The next step for strategic planning about research on simulation in healthcare should be to implement two mechanisms already used in fields of space sciences. One is a Science Traceability Structure that formally delineate Themes, Goals, and Objectives for the field and links them to Programs, Projects, and Methods. The second is the Decadal Survey, a highly detailed research planning activity conducted every ten years by scientific experts in the relevant fields, working under the auspices of the National Research Council. Decadal Surveys have unique characteristics, especially their extensive engagement with the research community, and their recommendations have generally been highly influential with policy-makers and legislators.

    View details for DOI 10.1097/SIH.0b013e31823ca729

    View details for Web of Science ID 000300414000005

    View details for PubMedID 22246468

  • Reporting Inquiry in Simulation SIMULATION IN HEALTHCARE Kardong-Edgren, S., Gaba, D., Dieckmann, P., Cook, D. A. 2011; 6: S63-S66


    The term "inquiry" covers the large spectrum of what people are currently doing in the nascent field of simulation. This monograph proposes appropriate means of dissemination for the many different levels of inquiry that may arise from the Summit or other sources of inspiration. We discuss various methods of inquiry and where they might fit in the hierarchy of reporting and dissemination. We provide guidance for deciding whether an inquiry has reached the level of development required for publication in a peer-reviewed journal and conclude with a discussion of what most journals view as inquiry acceptable for publication.

    View details for DOI 10.1097/SIH.0b013e318228610a

    View details for Web of Science ID 000294209700011

    View details for PubMedID 21817864

  • Where Do We Come From? What Are We? Where Are We Going? SIMULATION IN HEALTHCARE Gaba, D. M. 2011; 6 (4): 195-196

    View details for DOI 10.1097/SIH.0b013e31822802d4

    View details for Web of Science ID 000293577200001

    View details for PubMedID 21817865

  • Feasibility of an internet-based global ranking instrument. Journal of graduate medical education Mudumbai, S. C., Gaba, D. M., Boulet, J., Howard, S. K., Davies, M. F. 2011; 3 (1): 67-74


    Single-item global ratings are commonly used at the end of undergraduate clerkships and residency rotations to measure specific competencies and/or to compare the performances of individuals against their peers. We hypothesized that an Internet-based instrument would be feasible to adequately distinguish high- and low-ability residents.After receiving Institutional Review Board approval, we developed an Internet-based global ranking instrument to rank 42 third-year residents (21 in 2008 and 21 in 2009) in a major university teaching hospital's department of anesthesiology. Evaluators were anesthesia attendings and nonphysicians in 3 tertiary-referral hospitals. Evaluators were asked this ranking question: "When it comes to overall clinical ability, how does this individual compare to all their peers?"For 2008, 111 evaluators completed the ranking exercise; for 2009, 79 completed it. Residents were rank-ordered using the median of evaluator categorizations and the frequency of ratings per assigned relative performance quintile. Across evaluator groups and study years, the summary evaluation data consistently distinguished the top and bottom resident cohorts.An Internet-based instrument, using a single-item global ranking, demonstrated feasibility and can be used to differentiate top- and bottom-performing cohorts. Although ranking individuals yields norm-referenced measures of ability, successfully identifying poorly performing residents using online technologies is efficient and will be useful in developing and administering targeted evaluation and remediation programs.

    View details for DOI 10.4300/JGME-D-10-00162.1

    View details for PubMedID 22379525

  • Training and Nontechnical Skills: The Politics of Terminology SIMULATION IN HEALTHCARE Gaba, D. M. 2011; 6 (1): 8-10

    View details for DOI 10.1097/SIH.0b013e31820f9a55

    View details for Web of Science ID 000287076600004

    View details for PubMedID 21301283

  • Hospital safety climate and safety outcomes: is there a relationship in the VA? Medical care research and review Rosen, A. K., Singer, S., Shibei Zhao, Shokeen, P., Meterko, M., Gaba, D. 2010; 67 (5): 590-608


    Strengthening safety climate is recognized as a necessary strategy for improving patient safety. Yet there is little empirical evidence linking hospitals' safety climate with safety outcomes.The authors explored the potential relationship between safety climate and Veterans Health Administration hospital safety performance using the Patient Safety Indicator (PSI) rates. Safety climate survey data were merged with hospital discharge data to calculate PSIs. Linear regressions examined the relationship between hospitals' safety climate and dimensions of safety climate with individual PSIs and a PSI composite measure, controlling for organizational-level variables. Safety climate overall was not related to the PSIs or to the PSI composite, although a few individual dimensions of safety climate were associated with specific PSIs. Perceptions of frontline staff were more closely aligned with PSIs than those of senior managers.

    View details for DOI 10.1177/1077558709356703

    View details for PubMedID 20139397

  • Crisis resource management and teamwork training in anaesthesia BRITISH JOURNAL OF ANAESTHESIA Gaba, D. M. 2010; 105 (1): 3-6

    View details for DOI 10.1093/bja/aeq124

    View details for Web of Science ID 000278969500002

    View details for PubMedID 20551023

  • Use of Medical Simulation to Explore Equipment Failures and Human-Machine Interactions in Anesthesia Machine Pipeline Supply Crossover ANESTHESIA AND ANALGESIA Mudumbai, S. C., Fanning, R., Howard, S. K., Davies, M. F., Gaba, D. M. 2010; 110 (5): 1292-1296


    High-fidelity medical simulation can be used to explore failure modes of technology and equipment and human-machine interactions. We present the use of an equipment malfunction simulation scenario, oxygen (O(2))/nitrous oxide (N(2)O) pipeline crossover, to probe residents' knowledge and their use of anesthetic equipment in a rapidly escalating crisis.In this descriptive study, 20 third-year anesthesia residents were paired into 10 two-member teams. The scenario involved an Ohmeda Modulus SE 7500 anesthetic machine with a Datex AS/3 monitor that provided vital signs and gas monitoring. Before the scenario started, we switched pipeline connections so that N(2)O entered through the O(2) pipeline and vice versa. Because of the switched pipeline, the auxiliary O(2) flowmeter delivered N(2)O instead of O(2). Two expert, independent raters reviewed videotaped scenarios and recorded the alarms explicitly noted by participants and methods of ventilation.Nine pairs became aware of the low fraction of inspired O(2) (Fio(2)) alarm. Only 3 pairs recognized the high fraction of inspired N(2)O (Fin(2)o) alarm. One group failed to recognize both the low Fio(2) and the high Fin(2)o alarms. Nine groups took 3 or more steps before instigating a definitive route of oxygenation. Seven groups used the auxiliary O(2) flowmeter at some point during the management steps.The fact that so many participants used the auxiliary O(2) flowmeter may expose machine factors and related human-machine interactions during an equipment crisis. Use of the auxiliary O(2) flowmeter as a presumed external source of O(2) contributed to delays in definitive treatment. Many participants also failed to notice the presence of high N(2)O. This may have been, in part, attributable to 2 facts that we uncovered during our video review: (a) the transitory nature of the "high N(2)O" alert, and (b) the dominance of the low Fio(2) alarm, which many chose to mute. We suggest that the use of high-fidelity simulations may be a promising avenue to further examine hypotheses related to failure modes of equipment and possible management response strategies of clinicians.

    View details for DOI 10.1213/ANE.0b013e3181d7e097

    View details for Web of Science ID 000277130700010

    View details for PubMedID 20418294

  • Comparing safety climate in naval aviation and hospitals: Implications for improving patient safety HEALTH CARE MANAGEMENT REVIEW Singer, S. J., Rosen, A., Zhao, S., Ciavarelli, A. P., Gaba, D. M. 2010; 35 (2): 134-146


    Evidence of variation in safety climate suggests the need for improvement among at least some hospitals. However, comparisons only among hospitals may underestimate the improvement required. Comparison of hospitals with analogous industries may provide a broader perspective on the safety status of our nation's hospitals.The purpose of this study was to compare safety climate among hospital workers with personnel from naval aviation, an organization that operates with high reliability despite intrinsically hazardous conditions.We surveyed a random sample of health care workers in 67 U.S. hospitals and, for generalizability, 30 veterans affairs hospitals using questions comparable with those posed at approximately the same time (2007) to a census of personnel from 35 squadrons of U.S. naval aviators. We received 13,841 (41%) completed surveys in U.S. hospitals, 5,511 (50%) in veterans affairs hospitals, and 14,854 (82%) among naval aviators. We examined differences in respondents' perceptions of safety climate at their institution overall and for 16 individual items.Safety climate was three times better on average among naval aviators than among hospital personnel. Naval aviators perceived a safer climate (up to seven times safer) than hospital personnel with respect to each of the 16 survey items. Compared with hospital managers, naval commanders perceived climate more like frontline personnel did. When contrasting naval aviators with hospital personnel working in comparably hazardous areas, safety climate discrepancies increased rather than decreased. One individual hospital performed as well as naval aviation on average, and at least one hospital outperformed the Navy benchmark for all but three individual survey items.Results suggest that hospitals have not sufficiently created a uniform priority of safety. However, if each hospital performed as well as the top-performing hospital in each area measured, hospitals could achieve safety climate levels comparable with naval aviation. Major interventions to bolster hospital safety climate continue to be required to improve patient safety.

    View details for DOI 10.1097/HMR.0b013e3181c8b20c

    View details for Web of Science ID 000276557800005

    View details for PubMedID 20234220

  • The Pharmaceutical Analogy for Simulation: A Policy Perspective SIMULATION IN HEALTHCARE Gaba, D. M. 2010; 5 (1): 5-7

    View details for DOI 10.1097/SIH.0b013e3181c75ddb

    View details for Web of Science ID 000276077900002

    View details for PubMedID 20383083

  • Identifying organizational cultures that promote patient safety HEALTH CARE MANAGEMENT REVIEW Singer, S. J., Falwell, A., Gaba, D. M., Meterko, M., Rosen, A., Hartmann, C. W., Baker, L. 2009; 34 (4): 300-311


    Safety climate refers to shared perceptions of what an organization is like with regard to safety, whereas safety culture refers to employees' fundamental ideology and orientation and explains why safety is pursued in the manner exhibited within a particular organization. Although research has sought to identify opportunities for improving safety outcomes by studying patterns of variation in safety climate, few empirical studies have examined the impact of organizational characteristics such as culture on hospital safety climate.This study explored how aspects of general organizational culture relate to hospital patient safety climate.In a stratified sample of 92 U.S. hospitals, we sampled 100% of senior managers and physicians and 10% of other hospital workers. The Patient Safety Climate in Healthcare Organizations and the Zammuto and Krakower organizational culture surveys measured safety climate and group, entrepreneurial, hierarchical, and production orientation of hospitals' culture, respectively. We administered safety climate surveys to 18,361 personnel and organizational culture surveys to a 5,894 random subsample between March 2004 and May 2005. Secondary data came from the 2004 American Hospital Association Annual Hospital Survey and Dun & Bradstreet. Hierarchical linear regressions assessed relationships between organizational culture and safety climate measures.Aspects of general organizational culture were strongly related to safety climate. A higher level of group culture correlated with a higher level of safety climate, but more hierarchical culture was associated with lower safety climate. Aspects of organizational culture accounted for more than threefold improvement in measures of model fit compared with models with controls alone. A mix of culture types, emphasizing group culture, seemed optimal for safety climate.Safety climate and organizational culture are positively related. Results support strategies that promote group orientation and reduced hierarchy, including use of multidisciplinary team training, continuous quality improvement tools, and human resource practices and policies.

    View details for Web of Science ID 000270852700002

    View details for PubMedID 19858915

  • Comparing Safety Climate between Two Populations of Hospitals in the United States HEALTH SERVICES RESEARCH Singer, S. J., Hartmann, C. W., Hanchate, A., Zhao, S., Meterko, M., Shokeen, P., Lin, S., Gaba, D. M., Rosen, A. K. 2009; 44 (5): 1563-1584


    To compare safety climate between diverse U.S. hospitals and Veterans Health Administration (VA) hospitals, and to explore the factors influencing climate in each setting.Primary data from surveys of hospital personnel; secondary data from the American Hospital Association's 2004 Annual Survey of Hospitals.Cross-sectional study of 69 U.S. and 30 VA hospitals.For each sample, hierarchical linear models used safety-climate scores as the dependent variable and respondent and facility characteristics as independent variables. Regression-based Oaxaca-Blinder decomposition examined differences in effects of model characteristics on safety climate between the U.S. and VA samples.The range in safety climate among U.S. and VA hospitals overlapped substantially. Characteristics of individuals influenced safety climate consistently across settings. Working in southern and urban facilities corresponded with worse safety climate among VA employees and better safety climate in the U.S. sample. Decomposition results predicted 1.4 percentage points better safety climate in U.S. than in VA hospitals: -0.77 attributable to sample-characteristic differences and 2.2 due to differential effects of sample characteristics.Results suggest that safety climate is linked more to efforts of individual hospitals than to participation in a nationally integrated system or measured characteristics of workers and facilities.

    View details for DOI 10.1111/j.1475-6773.2009.00994.x

    View details for Web of Science ID 000269494600008

    View details for PubMedID 19619250

    View details for PubMedCentralID PMC2754548

  • How does patient safety culture in the operating room and post-anesthesia care unit compare to the rest of the hospital? AMERICAN JOURNAL OF SURGERY Kaafarani, H. M., Itani, K. M., Rosen, A. K., Zhao, S., Hartmann, C. W., Gaba, D. M. 2009; 198 (1): 70-75


    A strong patient safety culture in the operating room (OR) and post-anesthesia care unit (PACU) is essential to promote safe care.The Patient Safety Climate in Healthcare Organizations (PSCHO) survey was administered to employees at 30 Veterans Affairs (VA) hospitals. The survey consisted of 42 close-ended items representing 12 different dimensions of safety. We measured percent problematic response (PPR); higher PPR values reflect weaker safety culture. The "OR/PACU" and the "Other Work Areas" groups' item-specific, dimension-specific, and overall problematic responses were compared.The overall and dimension-specific PPRs were similar between the OR/PACU and the Other Work Areas group (overall: 20.2% and 18.1%, respectively; P = .41). When the 2 groups were compared on an item-by-item level, the OR/PACU staff reported more frequent witnessing of unsafe patient care (PPR 55.1% vs 43.2%; P = .01), and perceived less understanding by senior leadership of clinical care (PPR 28.3% vs 17.1%; P = .01) and less hospital interest in quality of care (PPR 20.4% vs 12.5%; P = .03).Specific areas of safety culture in the OR/PACU were found that should be targeted for improvement.

    View details for DOI 10.1016/j.amjsurg.2008.09.017

    View details for Web of Science ID 000267773600013

    View details for PubMedID 19268901

  • Do As We Say, Not As You Do: Using Simulation to Investigate Clinical Behavior in Action SIMULATION IN HEALTHCARE Gaba, D. M. 2009; 4 (2): 67-69

    View details for DOI 10.1097/SIH.0b013e3181a4a412

    View details for Web of Science ID 000277049900001

    View details for PubMedID 19444042

  • Relationship of Hospital Organizational Culture to Patient Safety Climate in the Veterans Health Administration MEDICAL CARE RESEARCH AND REVIEW Hartmann, C. W., Meterko, M., Rosen, A. K., Zhao, S., Shokeen, P., Singer, S., Gaba, D. M. 2009; 66 (3): 320-338


    Improving safety climate could enhance patient safety, yet little evidence exists regarding the relationship between hospital characteristics and safety climate. This study assessed the relationship between hospitals' organizational culture and safety climate in Veterans Health Administration (VA) hospitals nationally. Data were collected from a sample of employees in a stratified random sample of 30 VA hospitals over a 6-month period (response rate = 50%; n = 4,625). The Patient Safety Climate in Healthcare Organizations (PSCHO) and the Zammuto and Krakower surveys were used to measure safety climate and organizational culture, respectively. Higher levels of safety climate were significantly associated with higher levels of group and entrepreneurial cultures, while lower levels of safety climate were associated with higher levels of hierarchical culture. Hospitals could use these results to design specific interventions aimed at improving safety climate.

    View details for DOI 10.1177/1077558709331812

    View details for Web of Science ID 000265690500004

    View details for PubMedID 19244094

  • Coordination Patterns Related to High Clinical Performance in a Simulated Anesthetic Crisis ANESTHESIA AND ANALGESIA Manser, T., Harrison, T. K., Gaba, D. M., Howard, S. K. 2009; 108 (5): 1606-1615


    Teamwork is an integral component in the delivery of safe patient care. Several studies highlight the importance of effective teamwork and the need for teams to respond dynamically to changing task requirements, for example, during crisis situations. In this study, we address one of the many facets of "effective teamwork" in medical teams by investigating coordination patterns related to high performance in the management of a simulated malignant hyperthermia (MH) scenario. We hypothesized that (a) anesthesia crews dynamically adapt their work and coordination patterns to the occurrence of a simulated MH crisis and that (b) crews with higher clinical performance scores (based on a time-based scoring system for critical MH treatment steps) exhibit different coordination patterns.This observational study investigated differences in work and coordination patterns of 24 two-person anesthesia crews in a simulated MH scenario. Clinical and coordination behavior were coded using a structured observation system consisting of 36 mutually exclusive observation categories for clinical activities, coordination activities, teaching, and other communication. Clinical performance scores for treating the simulated episode of MH were calculated using a time-based scoring system for critical treatment steps. Coordination patterns in response to the occurrence of a crisis situation were analyzed using multivariate analysis of variance and the relationship between coordination patterns and clinical performance was investigated using hierarchical regression analyses. Qualitative analyses of the three highest and lowest performing crews were conducted to complement the quantitative analysis.First, a multivariate analysis of variance revealed statistically significant changes in the proportion of time spent on clinical and coordination activities once the MH crisis was declared (F [5,19] = 162.81, P < 0.001, eta(p)(2) = 0.98). Second, hierarchical regression analyses controlling for the effects of cognitive aid use showed that higher performing anesthesia crews exhibit statistically significant less task distribution (beta = -0.539, P < 0.01) and significantly more situation assessment (beta = 0.569, P < 0.05). Additional qualitative video analysis revealed, for example, that lower scoring crews were more likely to split into subcrews (i.e., both anesthesiologists worked with other members of the perioperative team without maintaining a shared plan among the two-person anesthesia crew).Our results of the relationship of coordination patterns and clinical performance will inform future research on adaptive coordination in medical teams and support the development of specific training to improve team coordination and performance.

    View details for DOI 10.1213/ane.0b013e3181981d36

    View details for Web of Science ID 000265422300040

    View details for PubMedID 19372344

  • Procedural Risks in Thoracentesis Process, Progress, and Proficiency CHEST Gaba, D. M., Dunn, W. F. 2009; 135 (5): 1120-1123

    View details for DOI 10.1378/chest.09-0306

    View details for Web of Science ID 000265876100004

    View details for PubMedID 19420191

  • Relationship of Safety Climate and Safety Performance in Hospitals HEALTH SERVICES RESEARCH Singer, S., Lin, S., Falwell, A., Gaba, D., Baker, L. 2009; 44 (2): 399-421


    To examine the relationship between measures of hospital safety climate and hospital performance on selected Patient Safety Indicators (PSIs).Primary data from a 2004 survey of hospital personnel. Secondary data from the 2005 Medicare Provider Analysis and Review File and 2004 American Hospital Association's Annual Survey of Hospitals.A cross-sectional study of 91 hospitals.Negative binomial regressions used an unweighted, risk-adjusted PSI composite as dependent variable and safety climate scores and controls as independent variables. Some specifications included interpersonal, work unit, and organizational safety climate dimensions. Others included separate measures for senior managers and frontline personnel's safety climate perceptions.Hospitals with better safety climate overall had lower relative incidence of PSIs, as did hospitals with better scores on safety climate dimensions measuring interpersonal beliefs regarding shame and blame. Frontline personnel's perceptions of better safety climate predicted lower risk of experiencing PSIs, but senior manager perceptions did not.The results link hospital safety climate to indicators of potential safety events. Some aspects of safety climate are more closely related to safety events than others. Perceptions about safety climate among some groups, such as frontline staff, are more closely related than perceptions in other groups.

    View details for DOI 10.1111/j.1475-6773.2008.00918.x

    View details for Web of Science ID 000264164400006

    View details for PubMedID 19178583

    View details for PubMedCentralID PMC2677046

  • Patient Safety Climate in 92 US Hospitals Differences by Work Area and Discipline MEDICAL CARE Singer, S. J., Gaba, D. M., Falwell, A., Lin, S., Hayes, J., Baker, L. 2009; 47 (1): 23-31


    Concern about patient safety has promoted efforts to improve safety climate. A better understanding of how patient safety climate differs among distinct work areas and disciplines in hospitals would facilitate the design and implementation of interventions.To understand workers' perceptions of safety climate and ways in which climate varies among hospitals and by work area and discipline.We administered the Patient Safety Climate in Healthcare Organizations survey in 2004-2005 to personnel in a stratified random sample of 92 US hospitals.We sampled 100% of senior managers and physicians and 10% of all other workers. We received 18,361 completed surveys (52% response).The survey measured safety climate perceptions and worker and job characteristics of hospital personnel. We calculated and compared the percent of responses inconsistent with a climate of safety among hospitals, work areas, and disciplines.Overall, 17% of responses were inconsistent with a safety climate. Patient safety climate differed by hospital and among and within work areas and disciplines. Emergency department personnel perceived worse safety climate and personnel in nonclinical areas perceived better safety climate than workers in other areas. Nurses were more negative than physicians regarding their work unit's support and recognition of safety efforts, and physicians showed marginally more fear of shame than nurses. For other dimensions of safety climate, physician-nurse differences depended on their work area.Differences among and within hospitals suggest that strategies for improving safety climate and patient safety should be tailored for work areas and disciplines.

    View details for Web of Science ID 000262186500004

    View details for PubMedID 19106727

  • Improvement in coronary anastomosis with cardiac surgery simulation JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Fann, J. I., Caffarelli, A. D., Georgette, G., Howard, S. K., Gaba, D. M., Youngblood, P., Mitchell, S., Burdon, T. A. 2008; 136 (6): 1486-1491


    Cardiac surgery trainees might benefit from simulation training in coronary anastomosis and more advanced procedures. We evaluated distributed practice using a portable task station and experience on a beating-heart model in training coronary anastomosis.Eight cardiothoracic surgery residents performed 2 end-to-side anastomoses with the task station, followed by 2 end-to-side anastomoses to the left anterior descending artery by using the beating-heart model at 70 beats/min. Residents took home the task station, recording practice times. At 1 week, residents performed 2 anastomoses on the task station and 2 anastomoses on the beating-heart model. Performances of the anastomosis were timed and reviewed.Times to completion for anastomosis on the task station decreased 20% after 1 week of practice (351 +/- 111 to 281 +/- 53 seconds, P = .07), with 2 residents showing no improvement. Times to completion for beating-heart anastomosis decreased 15% at 1 week (426 +/- 115 to 362 +/- 94 seconds, P = .03), with 2 residents demonstrating no improvement. Home practice time (90-540 minutes) did not correlate with the degree of improvement. Performance rating scores showed an improvement in all components. Eighty-eight percent of residents agreed that the task station is a good method of training, and 100% agreed that the beating-heart model is a good method of training.In general, distributed practice with the task station resulted in improvement in the ability to perform an anastomosis, as assessed by times to completion and performance ratings, not only with the task station but also with the beating-heart model. Not all residents improved, which is consistent with a "ceiling effect" with the simulator and a "plateau effect" with the trainee. Simulation can be useful in preparing residents for coronary anastomosis and can provide an opportunity to identify the need and methods for remediation.

    View details for DOI 10.1016/j.jtcvs.2008.08.016

    View details for Web of Science ID 000261970100016

    View details for PubMedID 19114195

  • Patient Safety Climate in US Hospitals Variation by Management Level MEDICAL CARE Singer, S. J., Falwell, A., Gaba, D. M., Baker, L. C. 2008; 46 (11): 1149-1156


    Strengthening hospital safety culture offers promise for reducing adverse events, but efforts to improve culture may not succeed if hospital managers perceive safety differently from frontline workers.To determine whether frontline workers and supervisors perceive a more negative patient safety climate (ie, surface features, reflective of the underlying safety culture) than senior managers in their institutions. To ascertain patterns of variation within management levels by professional discipline.A safety climate survey was administered from March 2004 to May 2005 in 92 US hospitals. Individual-level cross sectional comparisons related safety climate to management level. Hierarchical and hospital-fixed effects modeling tested differences in perceptions.Random sample of hospital personnel (18,361 respondents).Frequency of responses indicating absence of safety climate (percent problematic response) overall and for 8 survey dimensions.Frontline workers' safety climate perceptions were 4.8 percentage points (1.4 times) more problematic than were senior managers', and supervisors' perceptions were 3.1 percentage points (1.25 times) more problematic than were senior managers'. Differences were consistent among 7 safety climate dimensions. Differences by management level depended on discipline: senior manager versus frontline worker discrepancies were less pronounced for physicians and more pronounced for nurses, than they were for other disciplines.Senior managers perceived patient safety climate more positively than nonsenior managers overall and across 7 discrete safety climate domains. Patterns of variation by management level differed by professional discipline. Continuing efforts to improve patient safety should address perceptual differences, both among and within groups by management level.

    View details for Web of Science ID 000260745900004

    View details for PubMedID 18953225

  • An overview of patient safety climate in the VA HEALTH SERVICES RESEARCH Hartmann, C. W., Rosen, A. K., Meterko, M., Shokeen, P., Zhao, S., Singer, S., Falwell, A., Gaba, D. M. 2008; 43 (4): 1263-1284


    To assess variation in safety climate across VA hospitals nationally.Data were collected from employees at 30 VA hospitals over a 6-month period using the Patient Safety Climate in Healthcare Organizations survey.We sampled 100 percent of senior managers and physicians and a random 10 percent of other employees. At 10 randomly selected hospitals, we sampled an additional 100 percent of employees working in units with intrinsically higher hazards (high-hazard units [HHUs]).Data were collected using an anonymous survey design.We received 4,547 responses (49 percent response rate). The percent problematic response--lower percent reflecting higher levels of patient safety climate--ranged from 12.0-23.7 percent across hospitals (mean=17.5 percent). Differences in safety climate emerged by management level, clinician status, and workgroup. Supervisors and front-line staff reported lower levels of safety climate than senior managers; clinician responses reflected lower levels of safety climate than those of nonclinicians; and responses of employees in HHUs reflected lower levels of safety climate than those of workers in other areas.This is the first systematic study of patient safety climate in VA hospitals. Findings indicate an overall positive safety climate across the VA, but there is room for improvement.

    View details for DOI 10.1111/j.1475-6773.2008.00839.x

    View details for Web of Science ID 000257756000009

    View details for PubMedID 18355257

    View details for PubMedCentralID PMC2517282

  • Challenges and Opportunities in Simulation and Assessment SIMULATION IN HEALTHCARE Glavin, R. J., Gaba, D. M. 2008; 3 (2): 69-71

    View details for DOI 10.1097/SIH.0b013e31817bb8f6

    View details for Web of Science ID 000207536100001

    View details for PubMedID 19088644

  • Recruitment of hospitals for a safety climate study: facilitators and barriers. Joint Commission journal on quality and patient safety / Joint Commission Resources Rosen, A. K., Gaba, D. M., Meterko, M., Shokeen, P., Singer, S., Zhao, S., Labonte, A., Falwell, A. 2008; 34 (5): 275-284


    Despite increasing emphasis on safety culture assessment, little is known about the factors that affect hospitals' participation in such studies. Factors affecting recruitment of 30 Department of Veterans Affairs (VA) hospitals into a study to evaluate perceptions of safety culture, or safety "climate," were examined.To minimize selection bias, hospitals were recruited that represented the spectrum of safety performance on the basis of Patient Safety Indicator scores. Invitations and additional mailings, informational conference calls, and personal contact with hospitals were used to encourage participation. Investigators worked closely with hospitals' key stakeholders to obtain support and buy-in for the study. Relationships among safety performance, organizational culture, and other hospital characteristics with hospitals' participation and ease of recruitment were examined. Findings were compared with those of a companion study in the non-VA setting.Despite attempts to optimize recruitment, it was necessary to contact more than 90 hospitals to obtain a 30-hospital sample. Having a more entrepreneurial culture (associated with risk-taking, innovation, and quality improvement) was significantly related to shorter recruitment time in VA and non-VA settings. Safety performance was significantly related to participation in the VA (that is, "better-performing" hospitals were more likely to be recruited than "lower-performing" hospitals), but not in the non-VA study, where recruitment was based on size and region.Researchers should recruit representative samples of hospitals based on measures of safety performance. Hospital selection bias could lead to erroneous findings, ultimately impeding efforts to improve safety within organizations.

    View details for PubMedID 18491691

  • Differences in safety climate among hospital anesthesia departments and the effect of a realistic simulation-based training program ANESTHESIA AND ANALGESIA Cooper, J. B., Blum, R. H., Carroll, J. S., Dershwitz, M., Feinstein, D. M., Gaba, D. M., Morey, J. C., Singla, A. K. 2008; 106 (2): 574-584


    Safety climate is often measured via surveys to identify appropriate patient safety interventions. The introduction of an insurance premium incentive for simulation-based anesthesia crisis resource management (CRM) training motivated our naturalistic experiment to compare the safety climates of several departments and to assess the impact of the training.We administered a 59-item survey to anesthesia providers in six academic anesthesia programs (Phase 1). Faculty in four of the programs subsequently participated in a CRM program using simulation. The survey was readministered 3 yr later (Phase 2). Factor analysis was used to create scales regarding common safety themes. Positive safety climate (% of respondents with positive safety attitudes) was computed for the scales to indicate the safety climate levels.The usable response rate was 44% (309/708) and 38% (293/772) in Phases 1 and 2 respectively. There was wide variation in response rates among hospitals and providers. Eight scales were identified. There were significantly different climate scores among hospitals but no difference between the trained and untrained cohorts. The positive safety climate scores varied from 6% to 94% on specific survey questions. Faculty and residents had significantly different perceptions of the degree to which residents are debriefed about their difficult clinical situations.Safety climate indicators can vary substantially among anesthesia practice groups. Scale scores and responses to specific questions can suggest practices for improvement. Overall safety climate is probably not a good criterion for assessing the impact of simulation-based CRM training. Training alone was insufficient to alter engrained behaviors in the absence of further reinforcing actions.

    View details for DOI 10.1213/01.ane.0000296462.39953.d3

    View details for Web of Science ID 000252625700035

    View details for PubMedID 18227319

  • Trauma training in simulation: Translating skills from SIM time to real time 66th Annual Meeting of the American-Association-for-the-Surgery-of-Trauma Knudson, M. M., Khaw, L., Bullard, M. K., Dicker, R., Cohen, M. J., Staudenmayer, K., Sadjadi, J., Howard, S., Gaba, D., Krummel, T. LIPPINCOTT WILLIAMS & WILKINS. 2008: 255–63


    : Training surgical residents to manage critically injured patients in a timely fashion presents a significant challenge. Simulation may have a role in this educational process, but only if it can be demonstrated that skills learned in a simulated environment translate into enhanced performance in real-life trauma situations.: A five-part, scenario-based trauma curriculum was developed specifically for this study. Midlevel surgical residents were randomized to receiving this curriculum in didactic lecture (LEC) fashion or with the use of a human performance simulator (HPS). A written learning objectives test was administered at the completion of the training. The first four major trauma resuscitations performed by each participating resident were captured on videotape in the emergency department and graded by two experienced judges blinded to the method of training. The assessment tool used by the judges included an evaluation of both initial trauma evaluation or treatment skills (part I) and crisis management skills (part II) as well as an overall score (poor/fail, adequate, or excellent).: The two groups of residents received almost identical scores on the posttraining written test. Average SIM and LEC scores for part I were also similar between the two groups. However, SIM-trained residents received higher overall scores and higher scores for part II crisis management skills compared with the LEC group, which was most evident in the scores received for the teamwork category (p = 0.04).: A trauma curriculum incorporating simulation shows promise in developing crisis management skills that are essential for evaluation of critically injured patients.

    View details for DOI 10.1097/TA.0b013e31816275b0

    View details for Web of Science ID 000253287100001

    View details for PubMedID 18301184

  • Adaptive coordination in cardiac anaesthesia: a study of situational changes in coordination patterns using a new observation system ERGONOMICS Manser, T., Howard, S. K., Gaba, D. M. 2008; 51 (8): 1153-1178


    Patient care in hospital settings requires coordinated team performance. Studies in other industries show that successful teams adapt their coordination processes to the situational task requirements. This prospective field study aimed to test a new observation system and investigate patterns of adaptive coordination within operating room teams. A trained observer recorded coordination activities during 24 cardiac surgery procedures. The study tested whether different patterns occur during different phases of and between different types of surgical procedures (two-way multivariate ANOVA with repeated measure). A statistically significant increase was found in clinical and coordination activities in phases of the operation with high task interdependence. The highest level of 'coordination via the work environment' (i.e. an implicit coordination mechanism) was recorded during the actual procedure on the beating heart. These findings prove the sensitivity of the observation system developed and evaluated in this study and provide insight into patterns of adaptive coordination in cardiac anaesthesia. This study furthers our understanding of adaptive coordination as a cornerstone of effective team performance in complex work environments. Using a new observation system, it describes patterns employed by health care professionals in response to changing task demands in an acute patient care setting.

    View details for DOI 10.1080/00140130801961919

    View details for Web of Science ID 000257544400003

    View details for PubMedID 18608475

  • Workforce perceptions of hospital safety culture: Development and validation of the patient safety climate in healthcare organizations survey HEALTH SERVICES RESEARCH Singer, S., Meterko, M., Baker, L., Gaba, D., Falwell, A., Rosen, A. 2007; 42 (5): 1999-2021


    To describe the development of an instrument for assessing workforce perceptions of hospital safety culture and to assess its reliability and validity.Primary data collected between March 2004 and May 2005. Personnel from 105 U.S. hospitals completed a 38-item paper and pencil survey. We received 21,496 completed questionnaires, representing a 51 percent response rate.Based on review of existing safety climate surveys, we developed a list of key topics pertinent to maintaining a culture of safety in high-reliability organizations. We developed a draft questionnaire to address these topics and pilot tested it in four preliminary studies of hospital personnel. We modified the questionnaire based on experience and respondent feedback, and distributed the revised version to 42,249 hospital workers.We randomly divided respondents into derivation and validation samples. We applied exploratory factor analysis to responses in the derivation sample. We used those results to create scales in the validation sample, which we subjected to multitrait analysis (MTA).We identified nine constructs, three organizational factors, two unit factors, three individual factors, and one additional factor. Constructs demonstrated substantial convergent and discriminant validity in the MTA. Cronbach's alpha coefficients ranged from 0.50 to 0.89.It is possible to measure key salient features of hospital safety climate using a valid and reliable 38-item survey and appropriate hospital sample sizes. This instrument may be used in further studies to better understand the impact of safety climate on patient safety outcomes.

    View details for DOI 10.1111/j.1475-6773.2007.00706.x

    View details for Web of Science ID 000249429000012

    View details for PubMedID 17850530

    View details for PubMedCentralID PMC2254575

  • Deepening the theoretical foundations of patient simulation as social practice. Simulation in healthcare Dieckmann, P., Gaba, D., Rall, M. 2007; 2 (3): 183-193


    Simulation is a complex social endeavor, in which human beings interact with each other, a simulator, and other technical devices. The goal-oriented use for education, training, and research depends on an improved conceptual clarity about simulation realism and related terms. The article introduces concepts into medical simulation that help to clarify potential problems during simulation and foster its goal-oriented use. The three modes of thinking about reality by Uwe Laucken help in differentiating different aspects of simulation realism (physical, semantical, phenomenal). Erving Goffman's concepts of primary frames and modulations allow for analyzing relationships between clinical cases and simulation scenarios. The as-if concept by Hans Vaihinger further qualifies the differences between both clinical and simulators settings and what is important when helping participants engage in simulation. These concepts help to take the social character of simulation into account when designing and conducting scenarios. The concepts allow for improved matching of simulation realism with desired outcomes. It is not uniformly the case that more (physical) realism means better attainment of educational goals. Although the article concentrates on mannequin-based simulations that try to recreate clinical cases to address issues of crisis resource management, the concepts also apply or can be adapted to other forms of immersive or simulation techniques.

    View details for DOI 10.1097/SIH.0b013e3180f637f5

    View details for PubMedID 19088622

  • The role of debriefing in simulation-based learning. Simulation in healthcare Fanning, R. M., Gaba, D. M. 2007; 2 (2): 115-125

    View details for DOI 10.1097/SIH.0b013e3180315539

    View details for PubMedID 19088616

  • The tide is turning: organizational structures to embed simulation in the fabric of healthcare. Simulation in healthcare Gaba, D. M., Raemer, D. 2007; 2 (1): 1-3

    View details for DOI 10.1097/SIH.0b013e318031d644

    View details for PubMedID 19088601

  • Safety culture: Is the "unit" the right "unit of analysis"? CRITICAL CARE MEDICINE Gaba, D. M., Singer, S. J., Rosen, A. K. 2007; 35 (1): 314-316
  • Out of this nettle, danger, we pluck this flower, safety: healthcare vs. aviation and other high-hazard industries. Simulation in healthcare Gaba, D. M. 2007; 2 (4): 213-217

    View details for DOI 10.1097/SIH.0b013e31815ca23e

    View details for PubMedID 19088624

  • Improving alertness and performance in emergency department physicians and nurses: The use of planned naps ANNALS OF EMERGENCY MEDICINE Smith-Coggins, R., Howard, S. K., Mac, D. T., Wang, C., Kwan, S., Rosekind, M. R., Sowb, Y., Ballise, R., Levis, J., Gaba, D. M. 2006; 48 (5): 596-604


    We examine whether a 40-minute nap opportunity at 3 AM can improve cognitive and psychomotor performance in physicians and nurses working 12-hour night shifts.This is a randomized controlled trial of 49 physicians and nurses working 3 consecutive night shifts in an academic emergency department. Subjects were randomized to a control group (no-nap condition=NONE) or nap intervention group (40-minute nap opportunity at 3 AM=NAP). The main outcome measures were Psychomotor Vigilance Task, Probe Recall Memory Task, CathSim intravenous insertion virtual reality simulation, and Profile of Mood States, which were administered before (6:30 PM), during (4 AM), and after (7:30 AM) night shifts. A 40-minute driving simulation was administered at 8 AM and videotaped for behavioral signs of sleepiness and driving accuracy. During the nap period, standard polysomnographic data were recorded.Polysomnographic data revealed that 90% of nap subjects were able to sleep for an average of 24.8 minutes (SD 11.1). At 7:30 AM, the nap group had fewer performance lapses (NAP 3.13, NONE 4.12; p<0.03; mean difference 0.99; 95% CI: -0.1-2.08), reported more vigor (NAP 4.44, NONE 2.39; p<0.03; mean difference 2.05; 95% CI: 0.63-3.47), less fatigue (NAP 7.4, NONE 10.43; p<0.05; mean difference 3.03; 95% CI: 1.11-4.95), and less sleepiness (NAP 5.36, NONE 6.48; p<0.03; mean difference 1.12; 95% CI: 0.41-1.83). They tended to more quickly complete the intravenous insertion (NAP 66.40 sec, NONE 86.48 sec; p=0.10; mean difference 20.08; 95% CI: 4.64-35.52), exhibit less dangerous driving and display fewer behavioral signs of sleepiness during the driving simulation. Immediately after the nap (4 AM), the subjects scored more poorly on Probed Recall Memory (NAP 2.76, NONE 3.7; p<0.05; mean difference 0.94; 95% CI: 0.20-1.68).A nap at 3 AM improved performance and subjective report in physicians and nurses at 7:30 AM compared to a no-nap condition. Immediately after the nap, memory temporarily worsened. The nap group did not perform any better than the no-nap group during a simulated drive home after the night shift.

    View details for DOI 10.1016/j.annemergmed.2006.02.005

    View details for Web of Science ID 000241749400017

    View details for PubMedID 17052562

  • Use of cognitive aids in a simulated anesthetic crisis ANESTHESIA AND ANALGESIA Harrison, T. K., Manser, T., Howard, S. K., Gaba, D. M. 2006; 103 (3): 551-556


    We evaluated empirically the extent to which the use of a cognitive aid during a high-fidelity simulation of a malignant hyperthermia (MH) event facilitated the correct and prompt treatment of MH. We reviewed the management of 48 simulated adult MH scenarios; 24 involving CA 1 and 24 involving CA 2 residents. In the CA 1 group, 19 of the 24 teams (79%) used a cognitive aid, but only 8 of the 19 teams used it frequently or extensively. In the CA 2 group, 18 of the 23 teams (78%) used a cognitive aid but only 6 of them used it frequently or extensively. The frequency of cognitive aid use correlated significantly with the MH treatment score for the CA 1 group (Spearman r = 0.59, P < 0.01) and CA 2 group (Spearman r = 0.68, P < 0.001). The teams that performed the best in treating MH used a cognitive aid extensively throughout the simulation. Although the effect was less pronounced in the more experienced CA 2 cohort, there was still a strong correlation between performance and cognitive aid use. We were able to show a strong correlation between the use of a cognitive aid and the correct treatment of MH.

    View details for DOI 10.1213/01.ane.0000229718.02478.c4

    View details for Web of Science ID 000240049800007

    View details for PubMedID 16931660

  • What's in a name? A mannequin by any other name would work as well. Simulation in healthcare Gaba, D. M. 2006; 1 (2): 64-65

    View details for PubMedID 19088578

  • So many roads: facilitated debriefing in healthcare. Simulation in healthcare Dismukes, R. K., Gaba, D. M., Howard, S. K. 2006; 1 (1): 23-25

    View details for PubMedID 19088569

  • Clinicians' recognition of the Ohmeda Modulus II plus and Ohmeda Excel 210 SE anesthesia machine system mode and function. Simulation in healthcare Sowb, Y. A., Howard, S. K., Raemer, D. B., Feinstein, D., Fish, K. J., Gaba, D. M. 2006; 1 (1): 26-31


    : 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.: 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.: 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.: 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.

    View details for PubMedID 19088570

  • To simulate or not to simulate what is the question? ANNALS OF SURGERY Dutta, S., Gaba, D., Krummel, T. M. 2006; 243 (3): 301-303
  • The future's here. We are it. Simulation in healthcare Gaba, D. M. 2006; 1: 1-2

    View details for PubMedID 19088564

  • What makes a "good" anesthesiologist? ANESTHESIOLOGY Gaba, D. M. 2004; 101 (5): 1061-1063

    View details for Web of Science ID 000224738600002

    View details for PubMedID 15505439

  • The future vision of simulation in health care QUALITY & SAFETY IN HEALTH CARE Gaba, D. M. 2004; 13: I2-I10


    Simulation is a technique-not a technology-to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner. The diverse applications of simulation in health care can be categorised by 11 dimensions: aims and purposes of the simulation activity; unit of participation; experience level of participants; health care domain; professional discipline of participants; type of knowledge, skill, attitudes, or behaviours addressed; the simulated patient's age; technology applicable or required; site of simulation; extent of direct participation; and method of feedback used. Using simulation to improve safety will require full integration of its applications into the routine structures and practices of health care. The costs and benefits of simulation are difficult to determine, especially for the most challenging applications, where long term use may be required. Various driving forces and implementation mechanisms can be expected to propel simulation forward, including professional societies, liability insurers, health care payers, and ultimately the public. The future of simulation in health care depends on the commitment and ingenuity of the health care simulation community to see that improved patient safety using this tool becomes a reality.

    View details for DOI 10.1136/qshc.2004.009878

    View details for Web of Science ID 000224749200002

    View details for PubMedID 15465951

  • Validation of simulation-based training in neonatal resuscitation: Use of heart rate variability as marker for mental workload Annual Meeting of the Pediatric-Academic-Societies Murphy, A. A., Kaegi, D. M., Gobble, R., Dubin, A., Howard, S. K., Gaba, D. M., Sowb, Y. A., Halamek, L. P. NATURE PUBLISHING GROUP. 2004: 353A–353A
  • Trainee fatigue: Are new limits on work hours enough? CANADIAN MEDICAL ASSOCIATION JOURNAL Howard, S. K., Gaba, D. M. 2004; 170 (6): 975-976

    View details for Web of Science ID 000220242700028

    View details for PubMedID 15023924

  • Use of a fully simulated intensive care unit environment for critical event management training for internal medicine residents CRITICAL CARE MEDICINE Lighthall, G. K., Barr, J., Howard, S. K., Gellar, E., Sowb, Y., Bertacini, E., Gaba, D. 2003; 31 (10): 2437-2443
  • Trauma assessment training with a patient simulator: A prospective, randomized study 80th Annual Meeting of the American-College-of-Surgeons-Committee-on-Trauma Lee, S. K., Pardo, M., Gaba, D., Sowb, Y., Dicker, R., Straus, E. M., Khaw, L., Morabito, D., Krummel, T. M., Knudson, M. M. LIPPINCOTT WILLIAMS & WILKINS. 2003: 651–57


    Patient simulators are computer-controlled mannequins that may increase realism during trauma training by providing real-time changes in vital signs and physical findings during trauma scenarios. We hypothesized that trauma assessment training on a patient simulator would be as effective as training with a more traditional moulage patient/actor.This study was conducted during a surgery intern orientation at two academic trauma centers. Interns (n = 60) attended a basic trauma course, and were then randomized to trauma assessment practice sessions with either the patient simulator (n = 30) or a moulage patient (n = 30). After practice sessions, interns were randomized a second time to an individual trauma assessment test on either the simulator or the moulage patient. Two surgeon-judges rated each intern live and on video for completion of 50 predetermined assessment objectives (total score) divided into sections (primary and secondary survey, general performance, diagnostic studies/procedures, and plan) and the identification and management of an acute neurologic deterioration in the test patient (event score). Multiple linear regression with random student effects was used to estimate the independent effects of all study variables.Within randomized groups, mean trauma assessment test scores for all simulator-trained interns were higher when compared with all moulage-trained interns (71 +/- 8 vs. 66 +/- 8, respectively; p = 0.02). Simulator training independently showed a small but statistically significant improvement in both the total score and the event score (+4.6 and +8.6, respectively; p < 0.05).Use of a patient simulator to introduce trauma assessment training is feasible and compares favorably to training in a moulage setting. Continued research in this area of physician education is warranted.

    View details for DOI 10.1097/01.TA.0000035092.83759.29

    View details for Web of Science ID 000185991700012

    View details for PubMedID 14566118

  • Differences in safety climate between hospital personnel and naval aviators HUMAN FACTORS Gaba, D. M., Singer, S. J., Sinaiko, A. D., Bowen, J. D., Ciavarelli, A. P. 2003; 45 (2): 173-185


    We compared results of safety climate survey questions from health care respondents with those from naval aviation, a high-reliability organization. Separate surveys containing a subset of 23 similar questions were conducted among employees from 15 hospitals and from naval aviators from 226 squadrons. For each question a "problematic response" was defined that suggested an absence of a safety climate. Overall, the problematic response rate was 5.6% for naval aviators versus 17.5% for hospital personnel (p < .0001). The problematic response was 20.9% in high-hazard hospital domains such as emergency departments and operating rooms. Problematic response among hospital workers was up to 12 times greater than that among aviators on certain questions. Although further research on safety climate in health care is warranted, hospitals may need to make substantial changes to achieve a safety climate consistent with the status of high-reliability organizations.

    View details for Web of Science ID 000185151600001

    View details for PubMedID 14529192

  • Simulation study of rested versus sleep-deprived anesthesiologists ANESTHESIOLOGY Howard, S. K., Gaba, D. M., Smith, B. E., Weinger, M. B., Herndon, C., Keshavacharya, S., Rosekind, M. R. 2003; 98 (6): 1345-1355


    Sleep deprivation causes physiologic and subjective sleepiness. Studies of fatigue effects on anesthesiologist performance have given equivocal results. The authors used a realistic simulation environment to study the effects of sleep deprivation on psychomotor and clinical performance, subjective and objective sleepiness, and mood.Twelve anesthesia residents performed a 4-h anesthetic on a simulated patient the morning after two conditions of prior sleep: sleep-extended (EXT), in which subjects were allowed to arrive at work at 10:00 AM for 4 consecutive days, thus allowing an increase in nocturnal sleep time, and total sleep deprivation (DEP), in which subjects were awake at least 25 h. Psychomotor testing was performed at specified periods throughout the night in the DEP condition and at matched times during the simulation session in both conditions. Three types of vigilance probes were presented to subjects at random intervals as well as two clinical events. Task analysis and scoring of alertness were performed retrospectively from videotape.In the EXT condition, subjects increased their sleep by more than 2 h from baseline (P = 0.0001). Psychomotor tests revealed progressive impairment of alertness, mood, and performance in the DEP condition over the course of the night and when compared with EXT during the experimental day. DEP subjects showed longer response latency to vigilance probes, although this was statistically significant for only one probe type. Task analysis showed no difference between conditions except that subjects "slept" more in the DEP condition. There was no significant difference in the cases' clinical management between sleep conditions. Subjects in the DEP condition had lower alertness scores (P = 0.02), and subjects in the EXT condition showed little video evidence of sleepiness.Psychomotor performance and mood were impaired while subjective sleepiness and sleepy behaviors increased during simulated patient care in the DEP condition. Clinical performance between conditions was similar.

    View details for Web of Science ID 000183075400007

    View details for PubMedID 12766642

  • Emergency medicine crisis resource management (EMCRM): Pilot study of a simulation-based crisis management course for emergency medicine ACADEMIC EMERGENCY MEDICINE Reznek, M., Smith-Coggins, R., Howard, S., Kiran, K., Harter, P., Sowb, Y., Gaba, D., Krummel, T. 2003; 10 (4): 386-389


    To determine participant perceptions of Emergency Medicine Crisis Resource Management (EMCRM), a simulation-based crisis management course for emergency medicine.EMCRM was created using Anesthesia Crisis Resource Management (ACRM) as a template. Thirteen residents participated in one of three pilot courses of EMCRM; following a didactic session on principles of human error and crisis management, the residents participated in simulated emergency department crisis scenarios and instructor-facilitated debriefing. The crisis simulations involved a computer-enhanced mannequin simulator and standardized patients. After finishing the course, study subjects completed a horizontal numerical scale survey (1 = worst rating to 5 = best rating) of their perceptions of EMCRM. Descriptive statistics were calculated to evaluate the data.The study subjects found EMCRM to be enjoyable (4.9 +/- 0.3) (mean +/- SD) and reported that the knowledge gained from the course would be helpful in their practices (4.5 +/- 0.6). The subjects believed that the simulation environment prompted realistic responses (4.6 +/- 0.8) and that the scenarios were highly believable (4.8 +/- 0.4). The participants reported that EMCRM was best suited for residents (4.9 +/- 0.3) but could also benefit students and attending physicians. The subjects believed that the course should be repeated every 8.2 +/- 3.3 months.The EMCRM participants rated the course very favorably and believed that the knowledge gained would be beneficial in their practices. The extremely positive response to EMCRM found in this pilot study suggests that this training modality may be valuable in training emergency medicine residents.

    View details for Web of Science ID 000181995500016

    View details for PubMedID 12670855

  • The culture of safety: results of an organization-wide survey in 15 California hospitals QUALITY & SAFETY IN HEALTH CARE Singer, S. J., Gaba, D. M., Geppert, J. J., Sinaiko, A. D., Howard, S. K., Park, K. C. 2003; 12 (2): 112-118


    To understand fundamental attitudes towards patient safety culture and ways in which attitudes vary by hospital, job class, and clinical status.Using a closed ended survey, respondents were questioned on 16 topics important to a culture of safety in health care or other industries plus demographic information. The survey was conducted by US mail (with an option to respond by Internet) over a 6 month period from April 2001 in three mailings.15 hospitals participating in the California Patient Safety Consortium.A sample of 6312 employees generally comprising all the hospital's attending physicians, all the senior executives (defined as department head or above), and a 10% random sample of all other hospital personnel. The response rate was 47.4% overall, 62% excluding physicians. Where appropriate, responses were weighted to allow an accurate comparison between participating hospitals and job types and to correct for non-response.Frequency of responses suggesting an absence of safety culture ("problematic responses" to survey questions) and the frequency of "neutral" responses which might also imply a lack of safety culture. Responses to each question overall were recorded according to hospital, job class, and clinician status.The mean overall problematic response was 18% and a further 18% of respondents gave neutral responses. Problematic responses varied widely between participating institutions. Clinicians, especially nurses, gave more problematic responses than non-clinicians, and front line workers gave more than senior managers.Safety culture may not be as strong as is desirable of a high reliability organization. The culture differed significantly, not only between hospitals, but also by clinical status and job class within individual institutions. The results provide the most complete available information on the attitudes and experiences of workers about safety culture in hospitals and ways in which perceptions of safety culture differ among hospitals and between types of personnel. Further research is needed to confirm these results and to determine how senior managers can successfully transmit their commitment to safety to the clinical workplace.

    View details for Web of Science ID 000182156000011

    View details for PubMedID 12679507

  • No myth: Anesthesia is a model for addressing patient safety ANESTHESIOLOGY Cooper, J. B., Gaba, D. 2002; 97 (6): 1335-1337

    View details for Web of Science ID 000179590500002

    View details for PubMedID 12459657

  • Patient safety: Fatigue among clinicians and the safety of patients NEW ENGLAND JOURNAL OF MEDICINE Gaba, D. M., Howard, S. K. 2002; 347 (16): 1249-1255

    View details for Web of Science ID 000178598300007

    View details for PubMedID 12393823

  • The risks and implications of excessive daytime sleepiness in resident physicians ACADEMIC MEDICINE Howard, S. K., Gaba, D. M., Rosekind, M. R., Zarcone, V. P. 2002; 77 (10): 1019-1025


    To assess the levels of physiologic and subjective sleepiness in residents in three conditions: (1) during a normal (baseline) work schedule, (2) after an in-hospital 24-hour on-call period, and (3) following a period of extended sleep.In 1996, a within-subjects, repeated-measures study was performed with a volunteer sample of 11 anesthesia residents from the Stanford University School of Medicine using three separate experimental conditions. Sixteen residents were recruited and 11 of the 16 completed the three separate experimental conditions. Daytime sleepiness was assessed using the Multiple Sleep Latency Test (MSLT).MSLT scores were shorter in the baseline (6.7 min) and post-call (4.9 min) conditions, compared with the extended-sleep condition (12 min, p =.0001) and there was no significant difference between the baseline and post-call conditions (p =.07). There was a significant main effect for both condition (p =.0001) and time of day (p =.0003). Subjects were inaccurate in subjectively identifying sleep onset compared with EEG measures (incorrect on 49% of EEG-determined sleep episodes).Residents' daytime sleepiness in both baseline and post-call conditions was near or below levels associated with clinical sleep disorders. Extending sleep time resulted in normal levels of daytime sleepiness. The residents were subjectively inaccurate determining EEG-defined sleep onset. Based on the findings from this and other studies, reforms of residents' work and duty hours are justified.

    View details for Web of Science ID 000179365700013

    View details for PubMedID 12377678

  • Two examples of how to evaluate the impact of new approaches to teaching ANESTHESIOLOGY Gaba, D. M. 2002; 96 (1): 1-2

    View details for Web of Science ID 000173086000001

    View details for PubMedID 11752992

  • Patient safety and errors in medicine: Development, prevention and analyses of incidents. ANASTHESIOLOGIE INTENSIVMEDIZIN NOTFALLMEDIZIN SCHMERZTHERAPIE Rall, M., Manser, T., GUGGENBERGER, H., Gaba, D. M., Unertl, K. 2001; 36 (6): 321-330


    "Patient safety" and "errors in medicine" are issues gaining more and more prominence in the eyes of the public. According to newer studies, errors in medicine are among the ten major causes of death in association with the whole area of health care. A new era has begun incorporating attention to a "systems" approach to deal with errors and their causes in the health system. In other high-risk domains with a high demand for safety (such as the nuclear power industry and aviation) many strategies to enhance safety have been established. It is time to study these strategies, to adapt them if necessary and apply them to the field of medicine. These strategies include: to teach people how errors evolve in complex working domains and how types of errors are classified; the introduction of critical incident reporting systems that are free of negative consequences for the reporters; the promotion of continuous medical education; and the development of generic problem-solving skills incorporating the extensive use of realistic simulators wherever possible. Interestingly, the field of anesthesiology--within which realistic simulators were developed--is referred to as a model for the new patient safety movement. Despite this proud track record in recent times though, there is still much to be done even in the field of anesthesiology. Overall though, the most important strategy towards a long-term improvement in patient safety will be a change of "culture" throughout the entire health care system. The "culture of blame" focused on individuals should be replaced by a "safety culture", that sees errors and critical incidents as a problem of the whole organization. The acceptance of human fallability and an open-minded non-punitive analysis of errors in the sense of a "preventive and proactive safety culture" should lead to solutions at the systemic level. This change in culture can only be achieved with a strong commitment from the highest levels of an organization. Patient safety must have the highest priority in the goals of the institution: "Primum nihil nocere"--"First, do not harm".

    View details for Web of Science ID 000169707800002

    View details for PubMedID 11475625

  • Time for a new paradigm in pediatric medical education: Teaching neonatal resuscitation in a simulated delivery room environment PEDIATRICS Halamek, L. P., Kaegi, D. M., Gaba, D. M., Sowb, Y. A., Smith, B. C., Smith, B. E., Howard, S. K. 2000; 106 (4)


    Acquisition and maintenance of the skills necessary for successful resuscitation of the neonate are typically accomplished by a combination of completion of standardized training courses using textbooks, videotape, and manikins together with active participation in the resuscitation of human neonates in the real delivery room. We developed a simulation-based training program in neonatal resuscitation (NeoSim) to bridge the gap between textbook and real life and to assess trainee satisfaction with the elements of this program.Thirty-eight subjects (physicians and nurses) participated in 1 of 9 full-day NeoSim programs combining didactic instruction with active, hands-on participation in intensive scenarios involving life-like neonatal and maternal manikins and real medical equipment. Subjects were asked to complete an extensive evaluation of all elements of the program on its conclusion.The subjects expressed high levels of satisfaction with nearly all aspects of this novel program. Responses to open-ended questions were especially enthusiastic in describing the realistic nature of simulation-based training. The major limitation of the program was the lack of fidelity of the neonatal manikin to a human neonate.Realistic simulation-based training in neonatal resuscitation is possible using current technology, is well received by trainees, and offers benefits not inherent in traditional paradigms of medical education.

    View details for Web of Science ID 000089623100002

    View details for PubMedID 11015540

  • The National Patient Safety Foundation agenda for research and development in patient safety. MedGenMed : Medscape general medicine Cooper, J. B., Gaba, D. M., Liang, B., Woods, D., Blum, L. N. 2000; 2 (3): E38-?

    View details for PubMedID 11104484

  • Anaesthesiology as a model for patient safety in health care BRITISH MEDICAL JOURNAL Gaba, D. M. 2000; 320 (7237): 785-788

    View details for Web of Science ID 000086054700033

    View details for PubMedID 10720368

  • Landmark report published on patient safety JOURNAL OF CLINICAL MONITORING AND COMPUTING Gaba, D., Cooper, J. 2000; 16 (3): 231-232

    View details for Web of Science ID 000165379500011

    View details for PubMedID 12578109

  • Factors influencing vigilance and performance of anesthetists. Current opinion in anaesthesiology Howard, S. K., Gaba, D. M. 1998; 11 (6): 651-657


    As a group, anesthetists have been the leaders in medicine in the study of vigilance, performance, and safety. This review updates the work that has been done in the last year regarding the study of anesthetist vigilance and performance. Much of this work has been performed with the use of patient simulators.

    View details for PubMedID 17013286

  • Behavioral evidence of fatigue during a simulator experiment Howard, S. K., Keshavacharya, S., Smith, B. E., Rosekind, M. R., Weinger, M., Gaba, D. M. LIPPINCOTT WILLIAMS & WILKINS. 1998: U975–U975
  • Attitudes toward production pressure and patient safety: A survey of anesthesia residents JOURNAL OF CLINICAL MONITORING AND COMPUTING Healzer, J. M., Howard, S. K., Gaba, D. M. 1998; 14 (2): 145-146

    View details for Web of Science ID 000073777000010

    View details for PubMedID 9669453

  • Goals and functions of the human body: An MFM model for fault diagnosis IEEE TRANSACTIONS ON SYSTEMS MAN AND CYBERNETICS PART A-SYSTEMS AND HUMANS Larsson, J. E., HAYESROTH, B., Gaba, D. M. 1997; 27 (6): 758-765
  • Simulated anaesthetic emergencies BRITISH JOURNAL OF ANAESTHESIA Gaba, D. M., Howard, S. K. 1997; 79 (5): 689-690

    View details for Web of Science ID A1997YC73300030

    View details for PubMedID 9422915

  • Evaluation of a medical diagnosis system using simulator test scenarios ARTIFICIAL INTELLIGENCE IN MEDICINE Larsson, J. E., HAYESROTH, B., Gaba, D. M., Smith, B. E. 1997; 11 (2): 119-140


    This paper describes an informal but systematic method for how to test and verify a knowledge-based system in a large open-ended medical target domain. The system used is Guardian, an intelligent system for monitoring and diagnosis of post-cardiac surgery patients in an intensive-care unit. The knowledge base is tested and verified by running the system on a series of realistic test scenarios, both with an embedded simulator and with an external simulation system. The same scenarios are presented to human test subjects, making it possible to compare and analyze the performance of the knowledge-based system with that of human physicians. The use of simulators instead of clinical data also means that it is possible to test crucial scenarios which occur seldom in medical practice. Our results show that a system like Guardian might indeed be useful in medical care.

    View details for Web of Science ID A1997XX69900003

    View details for PubMedID 9332707

  • Anesthesia patient risk: A quantitative approach to organizational factors and risk management options RISK ANALYSIS PATECORNELL, M. E., Lakats, L. M., Murphy, D. M., Gaba, D. M. 1997; 17 (4): 511-523


    The risk of death or brain damage to anesthesia patients is relatively low, particularly for healthy patients in modern hospitals. When an accident does occur, its cause is usually an error made by the anesthesiologist, either in triggering the accident sequence, or failing to take timely corrective measures. This paper presents a pilot study which explores the feasibility of extending probabilistic risk analysis (PRA) of anesthesia accidents to assess the effects of human and management components on the patient risk. We develop first a classic PRA model for the patient risk per operation. We then link the probabilities of the different accident types to their root causes using a probabilistic analysis of the performance shaping factors. These factors are described here as the "state of the anesthesiologist" characterized both in terms of alertness and competence. We then analyze the effects of different management factors that affect the state of the anesthesiologist and we compute the risk reduction benefits of several risk management policies. Our data sources include the published version of the Australian Incident Monitoring Study as well as expert opinions. We conclude that patient risk could be reduced substantially by closer supervision of residents, the use of anesthesia simulators both in training and for periodic recertification, and regular medical examinations for all anesthesiologists.

    View details for Web of Science ID A1997XZ03600014

    View details for PubMedID 9323876

  • The effect of electronic record keeping and transesophageal echocardiography, on task distribution, workload, and vigilance during cardiac anesthesia ANESTHESIOLOGY Weinger, M. B., HERNDON, O. W., Gaba, D. M. 1997; 87 (1): 144-155


    Electronic anesthesia record keeping (EARK) systems increasingly are used in the operating room, but studies have only recently begun to investigate their effect on anesthesia task performance. Teak analysis, workload assessment, and vigilance assessment techniques were used to study senior residents providing anesthesia for coronary artery bypass graft (CABG) procedures. The impact on anesthesia residents' workload of the routine use of transesophageal echocardiography (TEE) also was examined.Before each case, the record keeping system was randomly selected as either electronic (Distek ARKIVE; EARK) or traditional manual recording (MAN). Twenty CABG procedures (10 EARK and 10 MAN) were examined, with observation commencing with anesthetic induction and terminating on initiation of cardiopulmonary bypass. The activities of each resident, divided into 32 task categories (e.g., "laryngoscopy," "observe monitors," etc.), were recorded by a trained observer using a computer. The response latency to a randomly activated alarm light was used as a measure of vigilance ("vigilance latency"). Workload was rated by subject and observer at random 10- to 15-min intervals throughout the case. Data analysis included calculation of workload density (number of tasks/min multiplied by task-specific workload values) and task-links (relationship between sequential tasks).The two groups had a similar distribution of tasks before intubation. In only 4 of the 20 cases studied did any manual record keeping occur before intubation. After intubation, the EARK group spent less time record keeping and using the TEE but more time observing the monitors and conversing with the attending physician than the MAN group did. All subjects reported significantly higher workload scores before intubation compared with after intubation. Similarly, vigilance latency was greater before intubation compared with after intubation (57 vs. 31 s; P < 0.001). There were no significant differences between the two record keeping groups in subjective workload scores, workload density, or vigilance latency. During TEE use, vigilance latency was significantly longer, and workload density was greater than during other monitoring or recording tasks.This study provides an objective description of the task distribution and workload during the administration of anesthesia for cardiac surgery. Under the conditions of this study. EARK use modestly decreased the time spent record keeping during the postintubation prebypass period. However, there was no effect of EARK either on vigilance or several measures of workload. TEE use was associated with increased workload and possibly decreased vigilance.

    View details for Web of Science ID A1997XJ86200023

    View details for PubMedID 9232145

  • Anesthesia providers, patient outcomes, and costs ANESTHESIA AND ANALGESIA Gaba, D. M. 1996; 83 (6): 1347-1348

    View details for Web of Science ID A1996VV54300043

    View details for PubMedID 8942616

  • Patient risk in anesthesia: Probabilistic risk analysis and management improvements ANNALS OF OPERATIONS RESEARCH PATECORNELL, E., Murphy, D., Lakats, L., Gaba, D. 1996; 67: 211-233
  • Anesthesia crisis resource management: Real-life simulation training in operating room crises JOURNAL OF CLINICAL ANESTHESIA Holzman, R. S., Cooper, J. B., Gaba, D. M., Philip, J. H., Small, S. D., Feinstein, D. 1995; 7 (8): 675-687


    Little formal training is provided in anesthesiology residency programs to help acquire, develop, and practice skills in resource management and decision making during crises in practice. Using anesthesia crisis resource management (ACRM) principles developed at another institution, 68 anesthesiologists and 4 nurse-anesthetists participated in an ACRM training course held over a 2 and a half-month period. The anesthesia environment was recreated in a real operating room, with standard equipment and simulations requiring actual performance of clinical interventions. Scenarios included overdose of inhalation anesthetic, oxygen source failure, cardiac arrest, malignant hyperthermia, tension pneumothorax, and complete power failure. A detailed questionnaire was administered following the debriefing and completed by all participants, documenting their immediate impressions. Participants rated themselves as having performed well in the simulator. Senior attendings and residents rated themselves more highly than did their junior counterparts. The potential benefit of this course for anesthesiologists to practice anesthesia more safely in a controlled exercise environment, was rated highly by both groups. Over one half of respondents in all categories felt that the course should be taken once every 12 months; another third of each group felt that the course should be taken once every 24 months. While no senior attendings believed that the course should be taken once every 6 months, approximately 10% of respondents in other categories that it should. Of respondents in the senior and junior attending category, 5% felt the course should never be taken. Although attendings were less favorable than residents in their rating of the value of the course, both groups were still enthusiastic.

    View details for Web of Science ID A1995TL94600007

    View details for PubMedID 8747567


    View details for Web of Science ID A1995RX59500021

    View details for PubMedID 8706209



    Situation awareness has primarily been confined to the aviation field. We believe that situation awareness is an equally important characteristic in the complex, dynamic, and risky field of anesthesiology. We describe three aspects of situations of which the decision maker must remain aware: subtle cues, evolving situations, and special knowledge elements. We provide examples of real or simulated anesthesia situations in which situation awareness is clearly involved in the provision of optimal patient care, and we map the elements of situation awareness onto a cognitive process model of the anesthesiologist. Finally, we consider how situation awareness can be further investigated and taught in this medical domain using anesthesia simulators and analyses of real cases. The study of situation awareness in anesthesiology may provide a good example of the wider application of the concept of situation awareness to nonaerospace environments.

    View details for Web of Science ID A1995RL73500003

    View details for PubMedID 7790008



    Pressure to put efficiency, output, or continued production ahead of safety has caused catastrophic accidents in various industries. The authors assessed the attitudes and experiences of anesthesiologists concerning production pressure.A random, repeated-mailing survey was conducted among 647 members of the American Society of Anesthesiologists residing in California. Questions were asked about attitudes toward production pressure and other patient safety issues, frequency of occurrence of various operating room events, encounters with situations involving unsafe actions, and ratings of sources of production pressure.Forty-seven percent of those sampled returned surveys. The demographics of the respondent population were largely similar to those of the population of anesthesiologists in California. There was no systematic difference between the respondents to the first versus the second mailing, reducing (but not eliminating) the possibility of self-selection bias. Nearly half (49%) of respondents had witnessed production pressure result in what they believed to be unsafe actions by an anesthesiologist. Such events included elective surgery in patients without adequate evaluation or with significant contraindications to surgery. Anesthesiologists felt pressures within themselves to work agreeably with surgeons, avoid delaying cases, and avoid litigation. They also reported overt pressure by surgeons to proceed with cases instead of cancelling them, and to hasten anesthetic procedures. Some aspects of production pressure were perceived differently by those reimbursed by fee-for-service versus those paid by salary.Production pressure from internal and external sources is a reality for many anesthesiologists and is perceived in some cases to have resulted in unsafe actions being performed.

    View details for Web of Science ID A1994PA47900026

    View details for PubMedID 8053599



    Administering anesthesia is a complex task in which either human or equipment failure can have disastrous consequences. An improved understanding of the nature of the anesthesiologist's job could provide a more rational basis for improvements in provider training as well as the design of anesthesia equipment. The objective of this study was to develop a set of techniques to evaluate anesthesiologist performance and to determine what information could be obtained from performing real-time task assessment and workload analysis tests in the operating room.The methodology used included time-motion analysis, secondary task probing, and subjective workload assessment. The time-motion data was subjected to subsequent analysis to generate quantitative measures such as task duration (time spent focused on an individual task) and task density (the number of tasks initiated per minute). The latency of response to a "vigilance light" was used as a secondary task probe. Finally, both the observer and the subjects themselves scored workload at 10-15-min intervals throughout the case. Two groups of anesthesia providers performing general endotracheal anesthesia for simple ambulatory surgical cases (1-4 h duration) were examined using this methodology. In the first group, 3rd-yr anesthesia residents and experienced certified registered nurse anesthetists (n = 11) performed cases under limited supervision by an attending anesthesiologist. In the second group, novice residents in their first 8 weeks of training (n = 11) performed similar cases under nearly constant attending supervision.The two groups seemed to manifest different patterns of task behavior, task density, subjective workload, and latency of response to the vigilance task. Response latency to the vigilance task increased at times of increased workload (e.g., during induction of anesthesia). The experienced (less supervised) providers spent significant amounts of time observing the monitors and the surgical field, whereas the novice subjects spent more time conversing with the supervising attending. Despite performing fewer tasks per minute (lower task densities), the novice subjects exhibited longer latencies of response to the vigilance light and increased subjective workload. Novice subjects also had longer task duration values. For example, postintubation, novices focused on their monitors for an average of twice as long as did experienced subjects (13 +/- 2 vs. 7 +/- 1 s) before moving on to another task.These techniques permitted an objective description of task characteristics, workload, and vigilance in anesthesia personnel under actual work conditions. This methodology could aid in understanding the factors that affect anesthesiologists' performance and may prove useful in assessing the progress of training.

    View details for Web of Science ID A1994MR30000015

    View details for PubMedID 8291734

  • GUARDIAN - A PROTOTYPE INTELLIGENT AGENT FOR INTENSIVE-CARE MONITORING 12th National Conference on Artificial Intelligence HAYESROTH, B., Uckun, S., Larsson, J. E., Gaba, D., Barr, J., Chien, J. M I T PRESS. 1994: 1503–1503
  • GUARDIAN - AN EXPERIMENTAL SYSTEM FOR INTELLIGENT ICU MONITORING 18th Annual Symposium on Computer Applications in Medical Care - Transforming Information, Changing Health Care HAYESROTH, B., Uckun, S., Larsson, J. E., DRAKOPOULOS, J., Gaba, D., Barr, J., Chien, J. BMJ PUBLISHING GROUP. 1994: 1004–1004

    View details for Web of Science ID A1994QF21600211

    View details for PubMedID 7949846



    The authors have developed a course in Anesthesia Crisis Resource Management (ACRM) analogous to courses in Crew (Cock-pit) Resource Management (CRM) conducted in commercial and military aviation. Anesthesiologists do not typically receive formal training in crisis management although they are called upon to manage life-threatening crises at a moment's notice. Two model demonstration courses in ACRM were conducted using a realistic anesthesia simulation system to test the feasibility and acceptance of this kind of training. Anesthesiologists received didactic instruction in dynamic decision-making, human performance issues in anesthesia, and in the principles of anesthesia crisis resource management. After familiarization with the host institution's operating rooms and with the simulation environment, they underwent a 2-h simulation session followed by a debriefing session which used a videotape of their simulator performance. Participants rated the course as intense, helpful to their practice of anesthesiology, and highly enjoyable. Several aspects of the course were highly rated, including: videotapes of actual anesthetic mishaps, simulation sessions, and debriefing sessions. Scores on written tests of knowledge about anesthesia crisis management showed a significant improvement following the first course (residents) but not the second course (experienced anesthesiologists). Although the ultimate utility of this training for anesthesiologists cannot easily be determined, the course appeared to be a useful method for addressing important issues of anesthesiologist performance which have previously been dealt with haphazardly. The authors believe that ACRM training should become a regular part of the initial and continuing education of anesthesiologists.

    View details for Web of Science ID A1992JK72800001

    View details for PubMedID 1524531

  • Bronchial cuff pressures of two tubes used in thoracic surgery. Journal of cardiothoracic and vascular anesthesia Kelley, J. G., Gaba, D. M., Brodsky, J. B. 1992; 6 (2): 190-192


    The pressure/volume characteristics of the bronchial cuff of a polyvinylchloride (PVC) double-lumen endobronchial tube (DLT) was compared with the inflatable cuff of a bronchial blocker. At the volumes needed to seal a series of rigid model bronchi the PVC DLT bronchial cuff consistently generated significantly lower pressures than the bronchial blocker cuff.

    View details for PubMedID 1568005

  • Case 2-1992. Unintentional delivery of vasoactive drugs with an electromechanical infusion device. Journal of cardiothoracic and vascular anesthesia Cook, R. I., Woods, D. D., Howie, M. B., Horrow, J. C., Gaba, D. M. 1992; 6 (2): 238-244

    View details for PubMedID 1568015


    View details for Web of Science ID A1992HL55800001

    View details for PubMedID 1550272

  • A comparison of etomidate and thiopental anesthesia for cardioversion. Journal of cardiothoracic and vascular anesthesia Ford, S. R., Maze, M., Gaba, D. M. 1991; 5 (6): 563-565


    Sixteen ASA class II or III male patients (aged, 52 to 66 years) undergoing elective cardioversion were randomly assigned to receive either thiopental or etomidate according to an observer-blinded, parallel study design. The appropriate drug was administered in 2-mL aliquots every 15 seconds until the patient no longer responded to verbal commands, at which time cardioversion was attempted. The total dose for induction was 0.22 +/- 0.2 mg/kg and 3.2 +/- 0.4 mg/kg for etomidate and thiopental, respectively. The cardiorespiratory data after induction were evaluated for maximal percent change from baseline. The baseline heart rate was 106 +/- 6 beats/min and 98 +/- 8 beats/min for the etomidate and thiopental groups, respectively (mean +/- SEM). The heart rate decreased 5% after induction with etomidate and increased 7% with thiopental (P less than 0.05). The baseline mean arterial pressure (MAP) was 96 +/- 3 mm Hg and 105 +/- 11 mm Hg for the etomidate and thiopental groups, respectively (mean +/- SEM). The MAP decreased 4% with etomidate and 3% with thiopental. Respiratory rate was significantly increased by 22% after etomidate compared with a 22% decrease in respiratory rate with thiopental (P less than 0.05). Seven of eight patients in the thiopental group required only one countershock, whereas four of eight patients in the etomidate group required only one shock. One patient in each group could not be successfully cardioverted. Recovery time and clinical side effects were similar between groups except for mild myoclonus in the etomidate group. Titration to effect of either etomidate or thiopental provided satisfactory anesthesia for elective cardioversion in hemodynamically stable patients.(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for PubMedID 1768819



    Eight experienced anesthesiologists (faculty or private practitioners) were presented with the same simulated critical incidents that had previously been presented to 19 anesthesia trainees. The detection and correction times for these incidents were measured, as was compliance with Advanced Cardiac Life Support (ACLS) guidelines during cardiac arrest, and the occurrence of unplanned incidents. Experienced personnel tended to react more rapidly than did trainees, but differences between second-year anesthesia residents (CA2) and experienced anesthesiologists were not statistically significant. There was a high variability in performance between incidents and within each group. Unplanned errors and management flaws still occurred with experience subjects. The response to incidents during anesthesia is a complex process that involves multiple levels of cognitive activity and is vulnerable to error regardless of experience. Most trainees seemed to acquire adequate response routines by the end of the CA2 year. Formal reasoning appeared to play a minor role in responding to intraoperative events, but the exact nature of the anesthesiologist's cognition remains to be thoroughly investigated.

    View details for Web of Science ID A1991EY85900006

    View details for PubMedID 1994759



    Workload is an important determinant of human performance during complex dynamic tasks. We indirectly measured the mental workload of nine anesthesia residents during 19 cases using a secondary (subsidiary) task paradigm in which performance on an extra task (problems in mathematical addition occurring approximately every 45 s) was used as a probe of a subject's "spare capacity." Excess response time (above baseline) correlated with activities like "manual task" and "speaking with the attending anesthesiologist." The addition problem was either skipped or had a high excess response time (greater than 30 s) in 40% of presentations. The complexity of a case and the experience level of the resident interacted in determining the workload. Subjective workload ratings confirmed that induction of and emergence from anesthesia were periods of highest workload, with "attention" as the dominant cognitive requirement. The anesthesiologist's spare capacity may often be limited during anesthesia. These types of workload measurement techniques should be applied in controlled studies to better define the factors that increase workload.

    View details for Web of Science ID A1990EA57500006

    View details for PubMedID 2400118


    View details for Web of Science ID A1990EA95100012

    View details for PubMedID 2230864



    In analyzing recordings of first- and second-year residents performing anesthesia in a comprehensive anesthesia simulation environment (CASE 1.2), we noted the occurrence of unplanned incidents. Utilizing a modified critical incident technique, we documented 132 unplanned incidents during 19 simulations (range 3-14, mean 6-947). Ninety-six (73%) of the incidents were considered simple incidents, and 36 (27%) were considered critical incidents. The incidents were classified as either human errors (65.9%), equipment failures (3%), fixation errors (20.5%), or unknown causes (10.6%). Human errors accounted for 87 of the incidents (range 1-12, mean 4.579), fixation errors accounted for 27 of the incidents (range 0-3, mean 1.421), and equipment failures accounted for only four of the incidents (range 0-2, mean 0.211). There was a significant (P less than 0.025) difference overall between resident groups, although no one class differed significantly from the others. The data confirm that most incidents are due to human error rather than equipment failure, and document fixation errors as a frequent cause of incidents in anesthesia. The data indicate that although most incidents are simple and do not progress into more serious incidents, human error remains ubiquitous, and that formal training and education should include recognition of events and the responses to them, in addition to prevention.

    View details for Web of Science ID A1990DK76300014

    View details for PubMedID 2363534

  • Corrigendum for bronchial diameters. Anesthesia and analgesia Brodsky, J. B., Gaba, D. M. 1990; 70 (6): 670-?

    View details for PubMedID 2344065



    Pressure damage to respiratory mucosa from overinflation of bronchial cuffs has been implicated as a cause of bronchial rupture, a rare but devastating complication of double-lumen endobronchial tubes (DLTs). We compared the pressure/volume characteristics of the bronchial cuffs of three different polyvinylchloride (PVC) DLTs and an equivalent sized red-rubber Robertshaw DLT. At the volume needed to seal effectively our bronchial model, two of the three PVC tube cuffs tested generated significantly less pressure than did that of the cuffs of the third PVC and the red-rubber Robertshaw tubes.

    View details for Web of Science ID A1989AX41300010

    View details for PubMedID 2802196


    View details for Web of Science ID A1989AK27500003

    View details for PubMedID 2670769



    While adverse outcomes linked to anesthesia are uncommon in healthy patients, they do occasionally happen. There is rarely a single cause. Anesthesia and surgery bring the patient into a complex world in which innumerable small failings can converge to produce an eventual catastrophe. And for all the technology involved, the anesthesiologist remains the cornerstone of safe anesthesia care, protecting the patient from harm regardless of its source. Responding to the demands of the operating room environment requires on-the-spot decision making in a complex, uncertain, and risky setting. Only responsible, professional human beings acting in concert can perform this task; no machine that we devise now or in the foreseeable future will suffice. I have outlined the components of a dynamic decision-making process that successfully protects patients in almost all cases. However, being human, anesthesiologists do make errors along the way--errors we are just beginning to understand. Sometimes these errors are due to faulty vigilance or incompetence, but usually they are made by appropriately trained, competent practitioners. Anesthesiologists can err in many ways, and recognizing these ways makes it easier to analyze the events leading to an anesthetic accident. More importantly, it better equips us to eliminate or minimize them in the future--and this is the real challenge.

    View details for Web of Science ID A1989AK27500002

    View details for PubMedID 2670768



    Using a comprehensive anesthesia simulation environment (CASE 1.2) we studied the response of anesthesia trainees (10 first-year residents and 9 second-year residents) to five simulated critical incidents: 1) endobronchial intubation; 2) kinked IV; 3) atrial fibrillation with hypotension; 4) breathing circuit disconnection; 5) cardiac arrest. Simulations were videotaped, and the response times for detecting and initiating correction of the problems were measured. Different problems had significantly different response characteristics. Breathing circuit disconnection and cardiac arrest were quickly detected (21 +/- 17 seconds; 7 +/- 5 seconds), and correction was begun quickly, although major errors in managing the cardiac arrest occurred in 58% of cases. Endobronchial intubation and atrial fibrillation took longer than the other problems to detect (105 +/- 142 seconds; 111 +/- 158 seconds) and to correct (555 +/- 358 seconds; 365 +/- 121 seconds). Intravenous kink was detected more slowly (238 +/- 269 seconds) but once discovered was quickly corrected. The response of different individuals was highly variable; experience level was a significant factor for correction (P = 0.03) but not for detection of problems overall. Because of high individual variation, experience was not a significant factor in correcting any signal problem. The data suggest that some types of problems are harder to handle than others and that individuals vary widely in their problem-handling abilities. Experience is a beneficial factor in anesthesia problem solving but not in a simple fashion. Vigilant detection of problems is only the first step in a complex response pathway that might be strengthened by improved protocols and repeated practice.

    View details for Web of Science ID A1989T941000003

    View details for PubMedID 2929977



    Simulation is used extensively in industries that involve routine, but risky activities. The authors describe an anesthesia simulation environment that provides a re-creation of the anesthesiologist's task environment in a real operating room. The system provides appropriate inputs to standard monitoring equipment in common use during anesthesia, including ECG (with arrhythmias); invasive systemic arterial, pulmonary arterial, and central venous pressures (all coupled to ECG arrhythmias); automated cuff blood pressure; pulse oximetry; mass spectrometry; breathing circuit spirometry; and oxygen analysis. An intubation/thorax mannequin allows tracheal intubation and tube manipulation, and provides for simulation of occlusion, malposition, or disconnection of the tracheal tube, as well as regurgitation of gastric contents. The simulation is comprehensive in that it is "hands-on" and requires actual performance of most interventions using actual equipment. The simulation is conducted by a systems operator and a simulation director; the latter also acts in the roles of surgeon and circulating nurse. The simulator outputs are determined by a "script" that defines the consequences of routine anesthetic actions and pre-established critical incidents. Decisions about timing and override of the script are made by the simulation director. This control system offers maximum flexibility while maintaining clinical realism. The simulator experiences were judged as highly realistic by 21 subjects. Limitations in this version have centered on the mannequin (e.g., no patient movement, minimal or confusing physical signs) and will be addressed in future versions of the system. The authors suggest that anesthesia simulation can be accomplished at nominal expense and has major potential for training, continuing education, certification, and research.

    View details for Web of Science ID A1988P966800017

    View details for PubMedID 3415018

  • Lactate extraction and myocardial damage after countershock at different energy levels. Journal of cardiothoracic anesthesia MAXWELL, M. S., DeAnda, A., Vickery, R., Gaba, D. M. 1988; 2 (3): 341-345


    The relationship between myocardial lactate metabolism and the energy dose of direct countershock was studied in 15 dogs anesthetized with halothane. Five dogs received two shocks of 5 joules delivered energy each, five animals received two shocks of 10 joules delivered energy each, and five dogs received two shocks of 20 joules delivered energy each. All animals had positive myocardial lactate extraction in the baseline state (5 joules, 38% +/- 23.7 (SD); 10 joules, 59.6% +/- 11.4; 20 joules, 38% +/- 11.1). Lactate extraction after countershock progressively decreased with increasing energy dose and then returned to baseline. The maximal reduction in percent lactate extraction increased with increasing energy dose (5 joules, 13.9% +/- 16.1; 10 joules, 33% +/- 37; 20 joules, 30.5% +/- 37.5) and seemed to reach a threshold below which no further decrease occurred. Myocardial damage, as measured by a damage index derived from myocardial uptake of technetium-99 pyrophosphate, increased steadily with increasing energy dose (2.0 +/- 2.5 with 5-joule shocks; 38 +/- 32 with 10 joules; and 99 +/- 70 with 20 joules). These results show a consistent reduction in aerobic metabolism immediately following electric countershock. Even at low-energy doses, myocardial lactate extraction showed a detectable decrease and at higher energies approached net lactate production. Reductions of global lactate extraction did not completely predict the amount of myocardial damage. Localized measures of anaerobic metabolism or mitochondrial function might provide a better correlation with localized damage.

    View details for PubMedID 17171870



    The authors studied the reduction in anesthetic requirement (MAC) and the hemodynamic effects of the highly selective alpha 2-adrenergic agonist azepexole in isoflurane-anesthetized dogs. Eleven male beagles were anesthetized with isoflurane in oxygen. After a 2-h equilibration period, they determined isoflurane MAC and baseline hemodynamic function. Azepexole (at 0.1, 0.3, and 1.0 mg/kg) was administered via a right atrial port over 15 min, while each dog was given isoflurane at the MAC dose for that animal. Twenty minutes after the end of infusion, at a time when hemodynamic variables were stable, they reassessed hemodynamic function. They then determined isoflurane MAC again. In other experiments, dogs were pretreated with either idazoxan (the alpha 2-adrenergic antagonist; n = 5) or naloxone (the opiate antagonist; n = 7) prior to the administration of azepexole. Isoflurane MAC was determined before and after each dose of azepexole. Isoflurane MAC decreased as the dose of azepexole increased, to the extent that at the highest dose (1 mg/kg) the decrement in MAC was more than 85%. This reduction of MAC caused by azepexole could be completely prevented by pretreatment with idazoxan, while naloxone was without effect. Azepexole did not change mean arterial blood pressure, but caused heart rate and cardiac output to progressively decrease. The MAC-reducing effect of azepexole appears to be mediated by alpha 2 adrenoreceptors. Given the extent of the reduction of MAC, it is unlikely that inhibition of central noradrenergic neurotransmission through agonism of presynaptic alpha 2 adrenoreceptors is the sole explanation, since complete disruption of central noradrenergic tracts decreases MAC by only 40%.(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1988N243200006

    View details for PubMedID 2897174


    View details for Web of Science ID A1988N204700024

    View details for PubMedID 3364777



    The effect of L-phenylisopropyladenosine (L-PIA), the A1 adenosine agonist, on the depth of anesthesia was investigated in halothane-anesthetized rats. L-PIA treatment reduced the minimum anesthetic concentration (MAC) of halothane that prevented 50% of animals from moving in response to a painful stimulus by 49%. MAC experiments performed with L-PIA given in conjunction with A1 adenosine receptor antagonists which either permeate the blood-brain barrier (8-phenyltheophylline [8-PT] or do not (8-sulphophenyltheophylline [8-So-PT]) indicate that central mechanisms are involved. Noradrenergic neurotransmission was diminished following L-PIA administration in halothane-anesthetized rats in all brain regions. These data suggest that acute L-PIA treatment decreases central noradrenergic neurotransmission and may represent the mechanism for the decrease in halothane dose to achieve an anesthetic endpoint anesthetic response to halothane.

    View details for Web of Science ID A1988M380900003

    View details for PubMedID 2832674



    Anesthesia and surgery are a risk for all, the healthy as well as the sick. While the prevention of adverse outcomes in healthy patients is paramount, enhancement of safety for critically ill patients is also essential, since they are more likely to suffer a SNO after a critical incident. Dangers originate from a variety of sources, not solely from errors by the anesthesiologist. Simple incidents of all description are inevitable, and we should focus on promoting recovery as well as avoiding error. Processes that lead to negative outcomes after critical incidents should be investigated to reduce the uncertainty complexity associated with managing the human body during anesthesia, and to establish the most effective detection and recovery techniques. Outcome studies are lacking, and clinical and animal research is highly dependent on the chosen model or population, making the results hard to apply to variable clinical conditions. Wherever possible, a consensus should be sought on therapeutic and adverse effects of drugs and techniques in common, specific patient populations. These can serve as a basis for developing therapeutic plans, recognizing that customizing to individuals is always necessary. A mainstay of anesthetic practice already involves attempts to loosen couplings, by keeping homeostatic mechanisms intact when possible (awake intubation, regional anesthesia); providing temporal buffers (titration of drugs, and use of drugs with short onset times and rapid termination of effect); and providing safety margins using appropriate pre-treatments (pre-oxygenation, atropine in children, etc.). Further means of loosening coupling should be identified and promoted. Specific attention to recovery from simple incidents should attack several facets of the problem.(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1987H133600013

    View details for PubMedID 3578880



    The global myocardial extraction of lactate was measured in 13 halothane anesthetized dogs to assess the effect of electric countershock applied directly to the heart. Seven animals received two countershocks of 30 delivered joules each, while six animals were not shocked but were atrially paced to a rate of 190-200, both with and without occlusion of the vena cava to produce a mean arterial pressure of 40-50 mmHg. All animals had substantially positive lactate extraction in the baseline state (36 +/- 10% for countershock group vs. 41 +/- 3% for pacing group). Myocardial lactate extraction reached a markedly negative nadir 2.5 min after countershock (-19 +/- 15%), but returned toward normal by 6 min (10 +/- 6%). Lactate extraction was not significantly changed from baseline in the pacing group. The relationship between changes in regional myocardial blood flow (radiolabeled microspheres) and post-countershock myocardial damage (technetium pyrophosphate uptake) was assessed in six dogs shocked as above. Mean myocardial blood flow was increased minimally immediately after countershock (0.78 +/- 0.08 ml X min-1 X g-1 vs. 1.16 +/- 0.3), but there was no difference in blood flow between damaged and undamaged tissue at either time point. The epicardial-to-endocardial ratio of blood flow was unchanged after countershock (0.97 +/- 0.05 vs. 0.99 +/- 0.08). There was no relationship between myocardial damage and either the absolute amount of blood flow after countershock (r = -0.03) or the change in blood flow compared with the pre-shock period (r = 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1987G748200005

    View details for PubMedID 3032021



    Endotracheal tube fires are the most frequent complication of laser surgery of the larynx. We investigated the incendiary characteristics of a new laser-resistant endotracheal tube, compared to polyvinyl chloride (PVC) and red rubber (RR) tubes, with different gas mixtures. A CO2 laser was focused on each tube and the probability of fire was assessed with oxygen fractions (FiO2) of 30%, 40%, 50%, 70%, and 100%, the balance being N2 or N2O. The laser-resistant tube could not be penetrated by a single laser pulse, regardless of laser energy or gas composition. PVC and RR tubes were readily ignited, the probability of ignition being related to oxygen concentration and laser energy. Nitrous oxide readily supported combustion. We suggest that laser surgery of the larynx can be most safely performed with a laser-resistant endotracheal tube and with gas mixtures containing the minimal safe O2 concentration (without nitrous oxide).

    View details for Web of Science ID A1986D194500009

    View details for PubMedID 3106892



    The authors determined the effect of acute and chronic aminophylline treatment on the arrhythmogenicity of epinephrine during halothane anesthesia. The dose of epinephrine required to achieve an arrhythmia threshold (ADE) was determined in nine unpremedicated dogs anesthetized with halothane (1.5% v/v) in oxygen (A0). Aminophylline was then infused to achieve and sustain a therapeutic theophylline level (mean +/- SD) of 17 +/- 2 micrograms X ml-1 (A1), at which time the ADE was reassessed. The aminophylline infusion regimen was then adjusted to provide a supratherapeutic level of theophylline of 34 micrograms X ml-1 (A2) and the ADE was reassessed. In an additional seven dogs the ADE was assessed before and after 6 weeks of oral aminophylline treatment that yielded a plasma theophylline level of 18 +/- 3 micrograms X ml-1. The ADE was significantly (P less than 0.01) reduced from a basal value (mean +/- SD) of 2.63 +/- 0.97 micrograms X kg X -1 X min-1 to 1.39 +/- 0.47 in the A1 state. There was no further decrement in the ADE at the A2 state (1.17 +/- 0.36). The plasma epinephrine level at the arrhythmia threshold decreased commensurately from 50.7 +/- 40.2 ng X ml-1 (A0) to 20.0 +/- 7.9 and 19.2 +/- 7.6 in the A1 and A2 states, respectively (P less than 0.01). In contrast to these acute treatment experiments, neither the ADE (2.65 +/- 0.95 vs. 2.97 +/- 1.49 micrograms X kg-1 X min-1) nor the plasma epinephrine levels at the arrhythmia threshold (47.2 +/- 13.7 vs. 51.1 +/- 22.0 ng X ml-1) were different after chronic aminophylline treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1986D115200003

    View details for PubMedID 3729049



    We report that the human standing potential, measured by the EOG, rises slowly when oxygen saturation is lowered to near 80% by breathing a controlled oxygen-nitrogen mixture. The standing potential falls abruptly by 20-30% of its amplitude when the oxygen saturation returns to 100%. These changes can be generated reproducibly, with minimal discomfort, under conditions that could be adopted for clinical use. Animal experimental studies by Linsenmeier and Steinberg suggest that this hypoxia-hyperoxia response may be a delayed response to potassium concentration changes in the subretinal space. Since there is no requirement for light and no involvement of the Müller cells, the hypoxia-hyperoxia response may be more specific for pigment epithelial pathology than the c-wave.

    View details for Web of Science ID A1985AUA2000002

    View details for PubMedID 4064875



    Transthoracic electric countershock can cause necrotic myocardial lesions in humans as well as experimental animals. The authors investigated the effect on postcountershock myocardial damage of pretreatment with prazosin (0.1 mg/kg), an alpha-1 antagonist; L-metoprolol (0.5 mg/kg), a beta-1 antagonist, and verapamil (0.5 mg/kg), a calcium channel-blocking agent. Twenty dogs were anesthetized with halothane and given two transthoracic countershocks of 295 delivered joules each after drug or vehicle treatment. Myocardial injury was quantitated 24 h following countershock by measuring the uptake of technetium-99m pyrophosphate in the myocardium. Elevated technetium-99m pyrophosphate uptake occurred in visible lesions in most dogs regardless of drug treatment. For each of four parameters of myocardial damage there was no statistically significant difference between control animals and those treated with prazosin, metoprolol, or verapamil. These data suggest that adrenergic or calcium channel-mediated mechanisms are not involved in the pathogenesis of postcountershock myocardial damage.

    View details for Web of Science ID A1985AGJ9600012

    View details for PubMedID 3994026


    View details for Web of Science ID A1985AJN1500015

    View details for PubMedID 4003800



    The authors determined whether increasing alpha 1-adrenergic blockade resulted in progressively less arrhythmic activity in the canine halothane-epinephrine arrhythmia model. Dogs (n = 7) were anesthetized with halothane (1.5%) in oxygen. Stepwise increases in steady-state plasma levels of either of two alpha 1-adrenoceptor antagonists (droperidol, doxazosin) were produced by applying Wagnerian principles to the known pharmacokinetic parameters of these drugs. At each steady state plasma level of these antagonists, the extent of the alpha 1-adrenergic blockade produced was assessed by defining a phenylephrine (PE) dose pressor response curve. The degree of alpha 1-blockade produced was quantitated as the dose of PE that caused a 25-mmHg increase in mean arterial pressure (ED25) as derived by polynomial regression analysis. By analysis of variance (ANOVA) the ED25 increased significantly for each targeted steady state plasma level of either droperidol (P less than 0.001) or doxazosin (P less than 0.001). For an assessment of the antiarrhythmic activity of these alpha 1-antagonists, the arrhythmogenic dose of epinephrine (ADE) was determined at each of the states of alpha 1-adrenergic blockade previously defined. By ANOVA there was a significant increase in the ADE over the range of alpha blockade produced for either droperidol (P less than 0.001) or doxazosin (P less than 0.001). A close correlation (r2) existed between the ED25 and the ADE for the target steady state levels that were achieved for either droperidol (0.99) or doxazosin (0.74).(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1985AVJ9200010

    View details for PubMedID 2865913



    The effect of transthoracic direct current countershock on the myocardium of 21 newborn piglets was studied. Myocardial damage was quantified by measuring the myocardial uptake of technetium-99m pyrophosphate injected 24 hours after countershock. Substantial myocardial damage occurred in animals given greater than 150 joules/kg but not at lower energy doses. Damage occurred in both ventricular free walls, but more frequently in the right ventricle. The epicardial half of the myocardium was more severely affected than the endocardial half. The relationship between myocardial damage and total countershock energy dose was well modeled by an exponential function. Transthoracic direct current countershock appears unlikely to cause myocardial damage in newborn piglets unless greatly elevated energy doses are employed.

    View details for Web of Science ID A1982NW49600004

    View details for PubMedID 6289274