james dean bauer md facog fics assistant professor clinical ob & gyn, ohsu modeling and errors...

James Dean Bauer MD FACOG FICS James Dean Bauer MD FACOG FICS Assistant Professor Clinical OB & GYN, Assistant Professor Clinical OB & GYN, OHSUOHSU

MODELING AND ERRORSMODELING AND ERRORS

Unweaving the Rainbow of Unweaving the Rainbow of SurgerySurgery

A New Way of CommunicationA New Way of Communication


OverviewOverview

Accident is a catastrophic expressions of human Accident is a catastrophic expressions of human error.error.Surgery has evolved into a technically complex Surgery has evolved into a technically complex endeavor that invites human error and system endeavor that invites human error and system failure.failure.Surgery is a definable and measurable processSurgery is a definable and measurable processErrors occur within the CONTEXT of a particular Errors occur within the CONTEXT of a particular operation’s defined process and sub processes.operation’s defined process and sub processes.Engineering tools (IDEF0) to analyze processes Engineering tools (IDEF0) to analyze processes in complex systems can help us define, in complex systems can help us define, understand, and control error. understand, and control error.


Nomenclature of ErrorsNomenclature of Errors

ErrorError will be taken as a generic term to encompass all will be taken as a generic term to encompass all those occasions in which a planned sequence of mental those occasions in which a planned sequence of mental or physical activities fails to achieve its intended or physical activities fails to achieve its intended outcome, and when these failures cannot be attributed to outcome, and when these failures cannot be attributed to the intervention of some chance agency.the intervention of some chance agency.

IntendedIntended– knowledge-base mistakesknowledge-base mistakes– rule-based mistakesrule-based mistakes– violationsviolations

UnintendedUnintended– slipsslips– lapseslapses

(Mandler, 1975; Woods, 1984)


Surgery Progressed from a Primitive Art to Surgery Progressed from a Primitive Art to Technical Endeavor Technical Endeavor


Surgicaltable

Surgeon FirstAssitant

Anesthesiologist

SurgicalAccessaries

ScrubNurse

BackTable

Human-Machine System Interaction Diagram-Closed

Documentation

Patient Support System

Anesth Delivery System

Patientheating &coolingsystem

Intravenous

DeliverySystem

Ventilator

Endoscopic Machinery

Insufflator VideoMonitor

Light Source Laparoscope

Surgical instruments

Physical System

Lamps

ElectricalSystem

Enviroment

CirculatingNurse

Surgical Team

HeadAbdominalcavity

Patient

Sharp Trocar/cannula

assembly

Support Material

CO2

material

energy

information

Verres Needle

Secondary Staff

Anesthesia

Monitors

GasDeliverySystem

Physiologic

Monitor

HVACSystem

VaccuumSys.

Mechanical System

FluidsSys. Bed

Mayo

Camera OperatingMicroscope

Computer UltrasonicTransducer

Scalpel

Electrosurgical Electrode

Existing Updated


““Factory Physics”Factory Physics”


Definition of SurgeryDefinition of Surgery

Surgery is a process that physically alters Surgery is a process that physically alters the patient’s anatomy through excision, the patient’s anatomy through excision, reconstruction, implantation, etc. in order reconstruction, implantation, etc. in order to diagnosis and treat. to diagnosis and treat. The surgical process transforms the The surgical process transforms the patient’s physiological state to a more patient’s physiological state to a more advantageous situation (state) for healing, advantageous situation (state) for healing, function, cosmesis and the relief of function, cosmesis and the relief of suffering suffering

(Bauer, 2003)


IDEF0IDEF0

Integrated DEFinition language 0Integrated DEFinition language 0Ideal for representing processes & functionsIdeal for representing processes & functionsGraphical modeling languageGraphical modeling language– Boxes: functionsBoxes: functions– Arrows: relationshipsArrows: relationships

Represents any level of abstractionRepresents any level of abstraction– ““Big picture”Big picture”– Fine detailsFine details

Depicts concurrency, functional dependencies Depicts concurrency, functional dependencies (not sequences)(not sequences)


PERFORM

SURGERY

PatientOR Ready

Documentation

Surgical GoalPatient Factors

Surgical Sys Factors4 Ps (Philosophy, Policies, Procedures, Practices)

Ready OR Team

Surgeon Nursing

Recovering Patient

Finished Documentation

OR to be Cleaned & RestockSurgical Specimens & Waste

Anesthetist


IDEF0 ConventionsIDEF0 Conventions

PERFORM

SURGERY

PatientOR Ready

Documentation

Surgical GoalPatient Factors

Surgical Sys Factors4 Ps (Philosophy, Policies, Procedures, Practices)

Ready OR Team

Recovering Patient

Finished Documentation

OR to be Cleaned & Restock

Inputs: systems and other things that are changed by the function

Function: a goal directed process

Mechanisms: actors (humans or machines) that perform the function

Controls: things that define the goal or/and guide, facilitate, or constrain the function

Outputs: the results of performing the function

Surgical Specimens & Waste


PerformLaparoscopicHysterectomy

Prepare Patientfor Surgery

Manage Patient’sPhysiology

Manage Patient’sPosition

Create &MaintainSurgical

Workspace

Restore SurgicalSystem to Neutral

State

Initiate PatientRecovery

Plan Surgery Perform SurgeryPrepare ORSystem for

Surgery

PrepareAnatomic Sitefor Procedure

Insert SecondaryTrocar

Close PatientExit Site & RegionPerform

Procedure

Insert PrimaryTrocar

InsufflateAbdomen

Insert & MangeLaparoscope

Plan and AssessWorkspace

Support ORFunctions

Plan & AssessSurgical

Procedure

Configure OR

DocumentWorkspace

Findings

Plan & AssessPrimaryTrocar

OpenAbdominal Wall

for PrimaryTrocar

Insert BluntTrocar

Secure TrocarSleeve to

AbdominalWall

Plan & AssessSecondary

Trocar

PrepareSecondary

Trocar

Select Sitesfor Secondary

Trocar

Incision forSecondary

Trocar

Secure Tubingto Trocar

ControlInsufflator

System

MaintainInternalSurgical

Space

Perform SurgicalProcedure

Plan & AssessInsufflation

Orient Camera

InsertLaparoscopeinto Trocar

Sleeve

ManageLaparoscope

Connect LightSource &Camera

Maintain ClearView of

Workspace

PushSecondaryTrocar in

IDEF0 HIERCHYIDEF0 HIERCHY







Workspace


State



Surgery


Insert SecondaryTrocars


Procedure


InsufflateAbdomen



Support ORFunctions


Procedure

Configure OR

DocumentWorkspace

Findings


OpenAbdominal Wall

for PrimaryTrocar

Insert BluntTrocar


AbdominalWall


Trocar

PrepareSecondary

Trocar


Trocar


Trocar


ControlInsufflator

System


Space



Orient Camera


Sleeve

ManageLaparoscope



Workspace







Workspace


State



Surgery




Procedure


InsufflateAbdomen



Support ORFunctions


Procedure

Configure OR

DocumentWorkspace

Findings


OpenAbdominal Wall

for PrimaryTrocar

Insert BluntTrocar


AbdominalWall


Trocar

PrepareSecondary

Trocar


Trocar


Trocar


ControlInsufflator

System


Space



Orient Camera


Sleeve

ManageLaparoscope



Workspace




IDEF0 (A0)IDEF0 (A0)

6

restore SurgSys to neutral

state

5

initiate Ptrecovery

A44

perform surgery

3

prepare ORSys for surgery

2

prepare Pt forsurgery

1

plan surgery

Pt factors

docs: updated

restore 4Ps

restore Surg Sys goal

rec 4Ps

Pt recovery goal

OR prep 4Pssurgery 4Ps

Pt prep 4Ps

surgical 4 Ps

OR Sys factors

surgical specimens

OR Sys:ready

for prep

Rec Sys: ready for Pt

Pre-op Sys: ready for prep

OR Sys factorsRec Sys factors

clean-up teamrecovery teamOR teamOR Prep teampre-op team

Pre-op Sys: used

Surg Sysprep goal

Pt prep goal

Pt: ready for prep

surgery goal

surgical team

surgical goal

waste

docs: open

Surg Sys factorsPt factors

OR Sys: usedPt: surgery performed

OR Sys: ready for surgery

Pt: prepped

surgical subgoals

Surg Sys: restored

Surg Sys: ready for prep

Pt: recovering







Workspace


State



Surgery




Procedure


InsufflateAbdomen



Support ORFunctions


Procedure

Configure OR

DocumentWorkspace

Findings


OpenAbdominal Wall

for PrimaryTrocar

Insert BluntTrocar


AbdominalWall


Trocar

PrepareSecondary

Trocar


Trocar


Trocar


ControlInsufflator

System


Space



Orient Camera


Sleeve

ManageLaparoscope



Workspace







Workspace


State



Surgery




Procedure


InsufflateAbdomen



Support ORFunctions


Procedure

Configure OR

DocumentWorkspace

Findings


OpenAbdominal Wall

for PrimaryTrocar

Insert BluntTrocar


AbdominalWall


Trocar

PrepareSecondary

Trocar


Trocar


Trocar


ControlInsufflator

System


Space



Orient Camera


Sleeve

ManageLaparoscope



Workspace




A455

performsurgical

procedure

4

managepatient

physiology

3

managepatient position

2

configure OR

1

support ORfunctions

conf OR 4Ps

Pt pos 4Ps

surg proc 4Ps

surg proc goalanesth goal

Pt pos goal

conf OR goal

anesth tools & matls: used

surg tools & matls: used

P pos tools & matls: used

OR config tools & matls: used

waste

OR Sys: used

support docs: updated

suppor docs: open

anesth docs: updated

surgery goal

Pt: surgery performed

surg docs: open

anesth docs: open

S FAA

CN

OR team

Pt: positioned

Pt: prepped

Pt: managed

OR Sys: configured

req for OR configreq for Pt pos

anesth 4Ps

surgery 4Ps

docs: updated

surg docs: updated

docs: open

OR Sys: ready for surgery

surg tools & matls: ready to use

Pt factors

req for tools & matls

req for Pt phys

tools & matls: ready to use

OR Sys factors

surgical specimens








Workspace


State



Surgery




Procedure


InsufflateAbdomen



Support ORFunctions


Procedure

Configure OR

DocumentWorkspace

Findings


OpenAbdominal Wall

for PrimaryTrocar

Insert BluntTrocar


AbdominalWall


Trocar

PrepareSecondary

Trocar


Trocar


Trocar


ControlInsufflator

System


Space



Orient Camera


Sleeve

ManageLaparoscope



Workspace







Workspace


State



Surgery




Procedure


InsufflateAbdomen



Support ORFunctions


Procedure

Configure OR

DocumentWorkspace

Findings


OpenAbdominal Wall

for PrimaryTrocar

Insert BluntTrocar


AbdominalWall


Trocar

PrepareSecondary

Trocar


Trocar


Trocar


ControlInsufflator

System


Space



Orient Camera


Sleeve

ManageLaparoscope



Workspace





6

close Pt

5

exit site &region

4

performprocedure

3

prep anatomicsite

A452

2

create &maintain

workspace

1

plan & assess

waste

OR Sys: used

Pt: surgery performed

Pt: managed

req for Pt pos

OR Sys factorssurg proc 4Ps

OR Sys: configured

surg docs: open

surg docs: updated

Pt: site exitedPt: proc completedPt: site prepped

Pt: workspace maintainedworkspace goal close goalexit goalproc goalsite goal

surg proc subgoals

surg proc goal

surgical specimens

Pt factors

req for Pt phys


S FA


req for OR config








Workspace


State



Surgery




Procedure


InsufflateAbdomen



Support ORFunctions


Procedure

Configure OR

DocumentWorkspace

Findings


OpenAbdominal Wall

for PrimaryTrocar

Insert BluntTrocar


AbdominalWall


Trocar

PrepareSecondary

Trocar


Trocar


Trocar


ControlInsufflator

System


Space



Orient Camera


Sleeve

ManageLaparoscope



Workspace







Workspace


State



Surgery




Procedure


InsufflateAbdomen



Support ORFunctions


Procedure

Configure OR

DocumentWorkspace

Findings


OpenAbdominal Wall

for PrimaryTrocar

Insert BluntTrocar


AbdominalWall


Trocar

PrepareSecondary

Trocar


Trocar


Trocar


ControlInsufflator

System


Space



Orient Camera


Sleeve

ManageLaparoscope



Workspace




6

documentworkspace

findings

A45255

insertsecondary

trocars

A45244

insert &manage

laparoscope

A45233

insufflateabdomen

A45222

insert primarytrocar

1

plan & assesssurg workspace

surg proc 4Ps

req for OR config

OR Sys factors

Pt factors

secondary trocar goal

Pt: wkspc visible

Pt: insufflated

Pt: prim trocar in

Pt: workspace maintained

Pt: managed

wkspc view goalinsuff goal

prim trocar goalworkspace subgoals

FA

S

req for Pt pos

req for Pt phys


waste


workspace goal

surg docs: updated

OR Sys: configuredsurg tools & matls: ready to use

OR Sys: used

surg docs: open








Workspace


State



Surgery




Procedure


InsufflateAbdomen



Support ORFunctions


Procedure

Configure OR

DocumentWorkspace

Findings


OpenAbdominal Wall

for PrimaryTrocar

Insert BluntTrocar


AbdominalWall


Trocar

PrepareSecondary

Trocar


Trocar


Trocar


ControlInsufflator

System


Space



Orient Camera


Sleeve

ManageLaparoscope



Workspace







Workspace


State



Surgery




Procedure


InsufflateAbdomen



Support ORFunctions


Procedure

Configure OR

DocumentWorkspace

Findings


OpenAbdominal Wall

for PrimaryTrocar

Insert BluntTrocar


AbdominalWall


Trocar

PrepareSecondary

Trocar


Trocar


Trocar


ControlInsufflator

System


Space



Orient Camera


Sleeve

ManageLaparoscope



Workspace




4

secure trocarsleeve to ab

wall

3

insert blunttrocar as prim

2

open ab wallfor prim trocar

1

plan & assessprim trocar

Pt factors

prim trocar secure goalprim trocar insert goalprim trocar open goal

prim trocar subgoal

surg proc 4PsOR Sys factors

FA Pt: prim trocar insertedPt: open for prim trocar


S

prim trocar goal

Pt: managed

Pt: prim trocar in

waste

OR Sys: used



req for OR config

req for Pt pos

req for Pt phys

OR Sys: configured

IDEF0 (A4522)IDEF0 (A4522)







Workspace


State



Surgery




Procedure


InsufflateAbdomen



Support ORFunctions


Procedure

Configure OR

DocumentWorkspace

Findings


OpenAbdominal Wall

for PrimaryTrocar

Insert BluntTrocar


AbdominalWall


Trocar

PrepareSecondary

Trocar


Trocar


Trocar


ControlInsufflator

System


Space



Orient Camera


Sleeve

ManageLaparoscope



Workspace







Workspace


State



Surgery




Procedure


InsufflateAbdomen



Support ORFunctions


Procedure

Configure OR

DocumentWorkspace

Findings


OpenAbdominal Wall

for PrimaryTrocar

Insert BluntTrocar


AbdominalWall


Trocar

PrepareSecondary

Trocar


Trocar


Trocar


ControlInsufflator

System


Space



Orient Camera


Sleeve

ManageLaparoscope



Workspace




4

maintaininternal space

3

controlinsufflatorsystem

2

secure tubingto trocar

1

plan & assessinsufflation

insuflator: controledprim troc: tubing on

Pt: insufflated

surg proc 4PsOR Sys factors

waste

OR Sys: used

req for OR config



req for Pt pos

req for Pt phys

Pt factorsint space goal

insufflator goalsec insuff tube goal

insufflation subgoals

S FA

insuff goal

Pt: prim trocar in


OR Sys: configured

IDEF0 (A4523)IDEF0 (A4523)







Workspace


State



Surgery




Procedure


InsufflateAbdomen



Support ORFunctions


Procedure

Configure OR

DocumentWorkspace

Findings


OpenAbdominal Wall

for PrimaryTrocar

Insert BluntTrocar


AbdominalWall


Trocar

PrepareSecondary

Trocar


Trocar


Trocar


ControlInsufflator

System


Space



Orient Camera


Sleeve

ManageLaparoscope



Workspace







Workspace


State



Surgery




Procedure


InsufflateAbdomen



Support ORFunctions


Procedure

Configure OR

DocumentWorkspace

Findings


OpenAbdominal Wall

for PrimaryTrocar

Insert BluntTrocar


AbdominalWall


Trocar

PrepareSecondary

Trocar


Trocar


Trocar


ControlInsufflator

System


Space



Orient Camera


Sleeve

ManageLaparoscope



Workspace




5

maintain clearview of

workspace

4

orient camera

3

insert lap intotrocar sleeve

2

connect lightsource &camera

1

managelaparoscope

req for Pt phys

req for OR config


waste

Pt: lap orientedPt: lap inLap: ready

Lap Sys: ready

S

clear workspc view goallap camera orient goallap insection goallaparoscope subgoal

lap setup goal

FA

wkspc view goal

Pt: wkspc visible

Pt: insufflated


OR Sys: conf igured

Pt factorsOR Sys factors

req for Pt pos


OR Sys: used

surg proc 4Ps

IDEF0 (A4524)IDEF0 (A4524)







Workspace


State



Surgery




Procedure


InsufflateAbdomen



Support ORFunctions


Procedure

Configure OR

DocumentWorkspace

Findings


OpenAbdominal Wall

for PrimaryTrocar

Insert BluntTrocar


AbdominalWall


Trocar

PrepareSecondary

Trocar


Trocar


Trocar


ControlInsufflator

System


Space



Orient Camera


Sleeve

ManageLaparoscope



Workspace







Workspace


State



Surgery




Procedure


InsufflateAbdomen



Support ORFunctions


Procedure

Configure OR

DocumentWorkspace

Findings


OpenAbdominal Wall

for PrimaryTrocar

Insert BluntTrocar


AbdominalWall


Trocar

PrepareSecondary

Trocar


Trocar


Trocar


ControlInsufflator

System


Space



Orient Camera


Sleeve

ManageLaparoscope



Workspace




5

push sectrocar in

4

incisition forsec trocar

3

selec sites forsec trocar

2

prepare sectrocar

1

plan & assesssecondary

trocar

secondary trocar: ready

req for OR config


Pt: incised for sec tracPt: sec troc sites selected

sec trcar goalsec troc in goalsec troc incision goalsec troc site goal

sec troc prep goal

sec trocar: prepared

Pt factors

SFA

Pt: workspace maintained

Pt: wkspc visible


OR Sys: configured

secondary trocar goal

req for Pt phys

req for Pt pos


OR Sys: used

waste

OR Sys factorssurg proc 4Ps

IDEF0 (A4525)IDEF0 (A4525)

Common Bile Duct AccidentCommon Bile Duct Accident

IDEFO Analysis of a Cascade IDEFO Analysis of a Cascade of Errorsof Errors

(Thanks & Appreciation to Dr. Rosser & Dr. Vazquez) (Thanks & Appreciation to Dr. Rosser & Dr. Vazquez)


Laparoscopic Cholecystectomy Laparoscopic Cholecystectomy IDEF0 Node TreeIDEF0 Node Tree

A0: performlaparoscopic

cholecystectomy

A2: preparepatient for surgery

A45: managepatient’s

physiology

A44: managepatient’sposition

A462: create &maintain surgical

workspace

A6: restoresurgical system to

neutral state

A5: initiate patientrecovery

A1: plan surgeryA4: perform

surgery

A3: prepare ORsystem for

surgery

A463: prepareanatomic site for

procedure

A466: closepatient

A465: exit site &region

A464: performprocedure

A42: support ORfunctions

A461: cognitiveprocessing of

procedure

A43: configureOR

A46: performsurgical

procedure

A41: maintainanatomic

orientation

A4641: cognitiveprocessingprocedure

A4642: ligate &divide cystic

duct

A4643: ligate &divide blood

source

A4644: disectgall bladder

from liver bed

A4645: removegall bladderfrom body

A46421: cognitiveprocessing

lapchole

A46422:exposure and

retraction

A46423:retroperitoneal

opening

A46424: isolatecystic duct

A46425: ligatecommon duct

A46426: dividecommon duct


Creating Surgical Workspace via Creating Surgical Workspace via LaparoscopyLaparoscopy

A4621: cognitiveprocessing surg

workspace

A4622: establishinitial port

A4623:maintain

pneumoperitoneum

A4624:visualize withlaparoscope

A4625: establishsecondary ports

A4626:documentworkspace

findings

A46241:Cognitive

processinglaparoscope

A46242: managelaparoscope

A46243:connect light

source & camera

A46244:position lap. into visualize site

A46245:maintain clear

view ofworkspace

A46231: cognitiveprocessing

pneumo

A46232: securetubing tocannula

A46233:control

insufflatorsystem

A46221:cognitive

processinginitial port

A46222: createinitial port

incision

A46223:create initial

pneumo

A46224:insert primary

instrument

A46225: securecannula

A46226:insert

laproscope intocannula

A462241: cognitiveprocessing prim

cannula

A462242:prepare can/troc

assembly

A462243: enlargeskin incision

A462244: push incan/trocassembly

A462245: removetrocar shaft

A462231:cognitive

processingpneumo creation

A462232: insertverres needle

A462233:secure tubing to

verres needle

A462234:provide gas thruverres needle

A462235:remove verres

needle

A4622321: cognitiveprocessing verres

needle

A4622322:elevate

abdominal wall

A4622323: insertverres needle

A4622324:check needle

displace &Intraperitoneal position


Recommended Configuration for Recommended Configuration for Operative Port Placement Operative Port Placement


Incorrect Third Port PlacementIncorrect Third Port Placement

FilmFilm Location of Third Port Location of Third Port Should be Lateral & Should be Lateral & Inferior in Relation to Inferior in Relation to Port #2 Port #2


Manage Laparoscope Video ImageManage Laparoscope Video Image

A4612: centertarget image

A4613:maintainrotational

orientation

A4616:sequence scan

pattern

A4615: correctillumination

A4614:maintainLscopedistance

A4611: determine& acquire target

image

A461: ManageLaparsope


Where the Mistakes Arise: Where the Mistakes Arise: Cognitive Processing Cognitive Processing

A4612:percieve &

sort objects

A4613:interpretsituation

A4616:sequence

response in time

A4615: mapresponse in 3D

space

A4614:determineresponse

A4611: visuallyscan


procedure


Incorrect Application of Retraction Incorrect Application of Retraction Forces Upon GB & Biliary TreeForces Upon GB & Biliary Tree

VideoVideo GB Infundibulum is GB Infundibulum is Pulled Medial as Pulled Medial as Opposed to LateralOpposed to Lateral

Distorted Biliary Distorted Biliary AnatomyAnatomy

Landmarks Difficult to Landmarks Difficult to Locate & IdentifyLocate & Identify

Anticipated Anatomic Anticipated Anatomic Relationships AlteredRelationships Altered



A4641: cognitiveprocessing lap/chole


duct

A4643: ligate &divide blood

source

A4644: disectgall bladder

from liver bed

A4645: removegall bladderfrom body


Disorientation & Cognitive Disorientation & Cognitive Confusion: A Flawed BeginningConfusion: A Flawed Beginning


duct

A46421: cognitiveprocessing cystic

duct

A46422:exposure and

retraction

A46423:retroperitoneal

opening

A46424: isolatecystic duct

A46425: ligatecommon duct

A46426: dividecommon duct


Hunter’s Recommendations Hunter’s Recommendations “Disorientation Countermeasures”“Disorientation Countermeasures”

Use 30 degree Use 30 degree scopescope

Lateral and Lateral and cephalad retraction cephalad retraction of fundusof fundus

Lateral and inferior Lateral and inferior retraction of retraction of infundibuluminfundibulum


Cognitive FixationCognitive Fixation

videovideo In the surgeon’s minds In the surgeon’s minds eye, the perceived eye, the perceived situation is Normal situation is Normal

Despite Altered Despite Altered RelationshipsRelationships

Despite Clues to the Despite Clues to the contrarycontrary

The proceeds according The proceeds according to a rigid planto a rigid plan


Violation of Hunter’s RulesViolation of Hunter’s Rules

There should be There should be adequate exposure of adequate exposure of the junction of the junction of Hartmann’s pouch Hartmann’s pouch and the cystic ductand the cystic ductAlways identify the Always identify the junction between the junction between the common bile duct and common bile duct and the cystic ductthe cystic ductNo structure should No structure should be divided until it is be divided until it is clearly identifiedclearly identified


Endpoint -- Division of the CBDEndpoint -- Division of the CBD

videovideo


Operative cholangiography Operative cholangiography should be routineshould be routine

A462: create &maintain surgical

workspace

A463: prepareanatomic site for

procedure

A466: closepatient

A465: exit site &region



procedure


The Swiss cheese model of how defenses, barriers, and safeguards may be penetrated by an accident trajectory.

Rasmussen’s Model of Accident Rasmussen’s Model of Accident CausationCausation

Reason J. BMJ 2000


Scientific Modeling and ThoughtTheodoric of Freiburg

“The first Unweaving of the Rainbow”

James D. Bauer MDSamaritan Health Services

Asst. Professor OB & GYN OHSUJames Burke (1995)


EpiphanyEpiphany

Engineering & Military Engineering & Military AviationAviation

Medicine & SurgeryMedicine & Surgery

james dean bauer md facog fics assistant professor clinical ob & gyn, ohsu modeling and errors...

Documents

relief of suffering

surgical process

system failure

complex endeavor

control error

patients physiological

sub processes

patients anatomy