Annotated Bibliography - Simulation Center - Stanford University School of Medicine

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	Theory of Patient Safety, Error, and Human Performance in Health Care
	Applications of Crew Resource Management (CRM) training to health care
	Realistic Simulation for Research and Training Concerning Human Performance in Health Care
	Effects of Sleep Deprivation and Fatigue on Health Care Personnel
	Human Factors, Psychology, and Risk Analysis of Safety in Health Care
	Artificial Intelligence and Automation in Health Care
	Bibliography (Steven K. Howard, M.D.)

Annotated Bibliography Concerning Patient Safety Issues
Patient Safety Center of Inquiry at VA Palo Alto Health Care System
Drs. Gaba, Howard, Smith, K Fish, Y Sowb, also P Fish - as of April, 2003

THEME: Theory of Patient Safety, Error, and Human Performance in Health Care (including organizational and systems analysis)

Gaba DM, Maxwell MS, DeAnda A: Anesthetic mishaps: Breaking the chain of accident evolution. Anesthesiology, 66:670-676, 1987
This was a ground-breaking paper applying principles from Perrow’s “Normal Accident Theory” to human error and patient safety in anesthesiology (and by extension much of health care in general).

Cooper JB, Gaba DM: A strategy for prevention of anesthetic mishaps. International Anesthesiology Clinics 27:148-152, 1989
This paper established strategies for reducing error and preventing mishaps. Different strategies were laid out for practitioners, institutions, professions, and the system as a whole.

Gaba DM, Howard SK: Conference on human error in anesthesia (meeting report). Anesthesiology 75:553-554, 1991
Drs. Gaba and Howard organized the international Conference On Human Error In Anesthesia , an experts’ workshop which brought together for the first time human factors experts (including David Woods) and medical personnel working on error and safety. The Conference catalyzed a number of research avenues by groups around the world.

Gaba DM: Analysis of the nasa Aviation Safety Reporting System (ASRS) as a model for safety reporting in anesthesiology. White Paper for the Anesthesia Patient Safety Foundation, 1992.
This paper outlined the applicability of the NASA ASRS system model to near miss and accident reporting in anesthesiology, and by extension the rest of health care. The APSF has been working toward establishment of such a program, which has remained stalled to date due to medicolegal issues.

Gaba DM: Human work environment and simulators. In Anesthesia, edited by Miller RD, 5th edition. New York: Churchill Livingstone, 1999, pp 2613-2668.
This chapter provides a very thorough review of information on human performance issues related to patient safety in anesthesiology. It also provides a comprehensive review (as of 1996-97) of the application of simulators in anesthesiology and other health care domains

Gaba DM: Structural and organizational issues in patient safety: A comparison of health care to other high-hazard industries. California Management Review 43:83-102, 2000
This groundbreaking publication discusses the structure of health care as an industry in comparison to other high-hazard industries. It challenges assumptions that health care is a high reliability organization. The suggestion is made that medical error is embedded deeply in industrial and organizational structure and practices of the health care industry.

Gaba DM, Howard SK, Jump B: Production pressure in the work environment: California anesthesiologists’ attitudes and experiences. Anesthesiology 81:488-500, 1994
A ground-breaking study demonstrating the prevalence of pressures to cut corners and to favor throughput and production over safety in anesthesiology.

Singer SJ, Gaba DM, Geppert JJ, Sinaiko AA, Howard SK, Park KC. The Culture of Safety: Results from an Organization-wide Survey in 15 California Hospitals. Quality and Safety in Health Care; 2003; 12:112-118.
A major paper investigating safety culture and climate throughout hospitals. While a majority answered in ways suggestive of a culture or climate of safety, a disturbingly high minority answered to the contrary. Significant differences were found between responses of executives and managers vs. front-line clinicians.

Gaba DM, Singer S, Sinaiko A, Ciavarelli A: Safety climate differences between hospital personnel and naval aviators. Human Factors; 2003, SUBMITTED

Also on this theme:

Gaba DM: Human error in anesthetic mishaps. International Anesthesiology Clinics 27:137-147,1989

Gaba DM: Human performance issues in anesthesia patient safety. Problems in Anesthesia 5:329-350, 1991

Gaba DM: Anesthesia is an unique complex dynamic world (position paper for Conference on human error in anesthesia), 1991

Gaba DM: Dynamic decision-making in anesthesiology: cognitive models and training approaches In Advanced Models of Cognition for Medical Training and Practice, edited by Evans DA, Patel VL. Berlin: Springer-Verlag, 1992, pp 123-147

Gaba DM: Human performance in dynamic medical domains. In Human Error in Medicine, edited by Bogner, MS. Hillsdale, N.J.: Lawrence Erlbaum Associates, 1994, pp. 197-224.

Botney R, Gaba DM: Human factors in monitoring. In Monitoring in Anesthesia and Critical Care, 3rd edition, edited by Blitt CD, Hines RL. New York: Churchill Livingstone, 1994, pp. 23-54.

Gaba DM: Risk, regulation, litigation, and organizational issues in safety in high-hazard industries. Position Paper for: Workshop on Organizational Analysis in High-Hazard Production Systems: An Academy/Industry Dialogue, 1996

Gaba DM: Strategies for data collection and analysis to protect patient safety in office-based anesthesia and surgery settings. Anesthesia Patient Safety Foundation Newsletter, Volume 14, Spring Issue, 2000

Gaba DM: Anaesthesiology as a model for patient safety in health care. Br Med J 320:785-788, 2000

Cooper JB, Gaba DM, Liang, B, Woods D, Blum, LN: The National Patient Safety Foundation Agenda for Research and Development in Patient Safety. MedGenMed, July 11, 2000 [available on-line at:

Gaba DM: Commentary (invited commentary on Masden LE: Diesel gas, rice, and medical errors (invited commentary). The Pharos, Winter, 2002.

Cooper JB, Gaba DM: No Myth: Anesthesia Is a Model for Addressing Patient Safety (editorial). Anesthesiology 2002; 97:1335–7

THEME: Applications of Crew Resource Management (CRM) training to health care

Howard SK, Gaba DM, Fish KJ, Yang GS, Sarnquist FH: Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviation, Space, and Environmental Medicine 63:763-770,.1992
This pioneering paper describes the derivation and application of Crew Resource Management training principles to the simulation-based training of anesthesiologists, resulting in a curriculum termed Anesthesia Crisis Resource Management (ACRM). This curriculum has now been adopted at a variety of centers around the world, and has been extended to other health care domains.

Gaba DM, Fish KJ, Howard SK: Crisis Management in Anesthesiology. New York, Churchill Livingstone, 1994
The textbook about crisis management in anesthesiology, and by extension to many other health care domains. This book is required reading for participants in CRM-type training courses in health care.

Halamek LP, Kaegi DM, Gaba DM, Sowb YA, Smith BC, Smith BE, Howard SK: Time for a new paradigm in pediatric medical education: Teaching neonatal resuscitation in a simulated delivery room environment. Pediatrics 106:(4) e45
A description of the initial experience with extending ACRM to the training of neonatologists and pediatricians regarding teamwork in neonatal resuscitation

Gaba DM, Howard SK, Fish KJ, Smith BE, Sowb YA: Simulation-based training in Anesthesia Crisis Resource Management (ACRM): a decade of experience. Simulation and Gaming: 32:175-193, 2001
This paper provides an review of ACRM and ACRM-like training, including more recent developments such as the multi-year ACRM curriculum, the “patient death scenario”, the pedagogical strategies of “Training Crews to Work in Teams”, “Combined Team Training” and assessment of performance.

Also on this theme:

Holzman RS, Cooper JB, Gaba DM, Philip JH, Small S, Feinstein D: Anesthesia crisis resource management: Real-life simulation training in operating room crises. Journal of Clinical Anesthesia 7: 675-687, 1995

Kurrek MM, Fish KJ: Anaesthesia crisis resource management training: an intimidating concept, a rewarding experience. Can J Anaesth 43:430-434, 1996

Halamek LP, Howard SK, Kaegi DM, Smith BE, Smith BC, Gaba DM: The simulated delivery room as a laboratory for the study of human performance (abstract). J Invest Med 46:167A, 1998

Sowb Y, Howard S, Gaba DM, Bushell E, Geller E, Barr J: Subjective assessment of an ACRM-based training for hospital ICU personnel (abstract). Anesthesia & Analgesia 2002; 94: S-129

Reznek M, Smith-Coggins R, Howard S, Kiran K, Sowb Y, Gaba D, Krummel T: Emergency Medicine Crisis Management (EMCM): Pilot study of a simulation-based crisis management course for emergency medicine. Acad Emerg Med In Press

THEME: Realistic Simulation for Research and Training Concerning Human Performance in Health Care

Gaba DM, DeAnda A: A comprehensive anesthesia simulation environment: Re-creating the operating room for research and teaching. Anesthesiology 69:387-394, 1988
The original description of the first modern patient simulator, invented at VA/Stanford. The commercially available Eagle Patient Simulator derives from this work (and from the 2nd generation simulator also developed at VA/Stanford).

Gaba DM, DeAnda A: The response of anesthesia trainees to simulated critical incidents. Anesthesia and Analgesia 68:444-451, 1989
The original research study on decision making of anesthesiologists using realistic simulation. As noted below several more studies of this type follower.

Gaba DM, Howard SK, Flanagan B, Smith BE, Fish KJ, Botney R: Assessment of clinical performance during simulated crises using both technical and behavioral ratings. Anesthesiology 89:8-18, 1998.
A large and complex study demonstrating the feasibility (and limitations) of assessing both technical performance of anesthesiologists and their performance at the key behaviors of crisis resource management

Reznek M, Smith-Coggins R, Howard S, Kiran K, Harter P, Sowb Y, Gaba D, Krummel T: Emergency Medicine Crisis Resource Management (EMCRM): Pilot Study of a Simulation-based Crisis Management Course for Emergency Medicine. Acad Emerg Med 2003; 10: 386-9.

Lighthall GK, Barr J, Howard SK, Geller E, Sowb Y, Bertaccini E, Gaba D: Use of a Fully Simulated ICU Environment for Critical Event Management Training for Internal Medicine Residents. Critical Care Medicine, 2002, In Press

Also on this theme:

DeAnda A, Gaba DM: Unplanned incidents during comprehensive anesthesia simulation. Anesth Analg 71:77-82, 1990

DeAnda A, Gaba DM: The role of experience in the response to simulated critical incidents. Anesth Analg 72:308-315, 1991

Gaba, DM: Improving anesthesiologists’ performance by simulating reality (editorial). Anesthesiology 76:491-494, 1992

Gaba DM: Anesthesia simulators -- a virtual reality. American Society of Anesthesiologists Newsletter. 57 (8):20-23, August, 1993

Botney R, Gaba DM, Howard SK, Jump B: The role of fixation error in preventing the detection and correction of a simulated volatile anesthetic overdose. Anesthesiology 79: A1115, 1993

Botney R, Gaba DM, Howard SK: Anesthesiologist performance during a simulated loss of pipeline oxygen. Anesthesiology 79: A1118, 1993

Gaba DM: Full scale anesthesia simulators in the United States. In Anesthesia: Implications for the Coming Century, edited by Ikeda K, Kazama T, Katoh T, Doi M, Takahashi H. Tokyo: Churchill Livingstone Japan, 1996, pp15-23.

Gaba DM:Simulators in Anesthesia. In Advances in Anesthesia, edited by Lake, C. St. Louis: Mosby-Year Book, Inc., Volume 14, 1996, pp 55-94.

Gaba DM: Patient simulators. In Anesthesia Equipment, 2nd edition, edited by Ehrenwerth J, Eisenkraft JB. St. Louis: Mosby, (In Press)

Sowb YA, Loeb RG, Smith BE, Cognitive Performance During Simulated Ventilation-Related Events, Anesthesiology 1997; A-943

Smith BE, Loeb RG, Gaba DM, Weinger M. Simulation in Human Factors Research: A Progress Report, Society for Technology in Anesthesia Abstract/Poster, 1998

Devitt HJ, Kurrek MM, Cohen MM, Fish KJ, Fish MP, Murphy PM, Szalai J. Testing the raters: Inter-rater reliability during observation of anaesthesia simulator performance. Canadian Journal of Anaesthesia 44:924-928, 1997

Fish MP, Flanagan B. Incorporation of a Realistic Anesthesia Simulator into an Anesthesia Clerkship. In Simulators in Anesthesiology Education, edited by Henson L, Lee A, Basford A. New York: Plenum Publishing Corporation, 1998.

Gaba DM: Research techniques in human performance using realistic simulation, In Simulators in Anesthesiology Education, edited by Henson L, Lee A, Basford A. New York: Plenum Publishing Corporation, 1998, pp. 93-102.

Smith BE, Gaba DM: Simulators. In Clinical Monitoring: Practical Applications for Anesthesia and Critical Care, edited by Lake C, Blitt C, Hines R. Philadelphia: W. B. Saunders, 2001, pp. 26-44.

Devitt HJ, Kurrek MM, Cohen MM, Fish KJ, Fish P, Noel AG, Szalai J. Testing Internal Consistency and Construct Validity During Evaluation of Performance in an Anesthesia Simulator (submitted)

Gaba DM: Two examples of how to evaluate the impact of new approaches to teaching (editorial). Anesthesiology 96:1-2, 2002

Bushell E, Gaba DM: Anesthesia simulation and patient safety. Problems in Anesthesia, 13:506-514, 2001

THEME: Effects of Sleep Deprivation and Fatigue on Health Care Personnel

Howard SK, Gaba DM: Human Performance and Patient Safety. In Patient Safety in Anesthetic Practice, edited by Morrell R, Eichhorn J. New York: Churchill Livingstone, 1997, pp. 431-466
This chapter is largely about sleep deprivation and fatigue issues, reviewing the literature on the topic, discussing findings from our laboratory, and suggesting avenues of approach for countermeasures

Howard SK, Gaba DM, Rosekind MR, Zarcone VP: Excessive Daytime Sleepiness In Resident Physicians: Risks, Intervention, And Implications. Acad Med 77:1019-1025, 2002
This paper provides the first scientific documentation of the magnitude of sleep debt in health care personnel, showing that both in the baseline and post-call state the physicians had levels of daytime sleepiness at or worse than that of patients with narcolepsy or sleep apnea.

Gaba DM, Howard SK: Fatigue among clinicians and the safety of patients. New Engl J Med 347:1249-1255, 2002
This is a major policy review of fatigue and safety in health care compared to other high hazard industries.

Howard SK, Rosekind MR, Katz JD, Berry AJ. Fatigue in Anesthesia: Implications and Strategies for Patient and Provider Safety. Anesthesiology 97:1281–94, y 2002;
This paper is a major scientific review of circadian and sleep physiology, performance issues, policies and countermeasures related to anesthesiology.

Howard SK, Gaba DM, Smith BE, Weinger MB, Herndon C, Keshavacharya S, Rosekind MR: Simulation study of rested versus sleep deprived anesthesiologists. Anesthesiology, 2002, IN PRESS

Also on this theme:

Howard SK, Smith BE, Gaba DM, Rosekind MR: Performance of well-rested vs. highly-fatigued residents: A simulator study (abstract). Anesthesiology 1997; 87:A:981

Howard SK, Healzer JM, Gaba DM: Sleep and work schedules of anesthesia residents: A national survey (abstract). Anesthesiology 1997; 87:A932

Howard S, Keshavacharya S, Smith B, Rosekind M, Weinger M, Gaba D: Behavioral evidence of fatigue during a simulator experiment (abstract). Anesthesiology 1998; 89: A1236

Herndon CN, Weinger MB, Smith BE, Howard SK, Rosekind MR, Gaba DM: Use of task analysis to evaluate the effects of fatigue on performance during simulated anesthesia cases (abstract). Anesthesiology 1998; 89: A1180

Smith-Coggins R, Rosekind MR, Hurd S, Buccino KR. Relationship of day versus night sleep to physician performance and mood. Annals of Emergency Medicine 1994; 24:928-34.

Smith-Coggins R, Rosekind MR, Buccino KR, Dinges DF, Moser RP. Rotating shiftwork schedules: can we enhance physician adaptation to night shifts. Acad Emerg Med 1997; 4:951-61.

THEME: Human Factors, Psychology, and Risk Analysis of Safety in Health Care

Gaba DM, Lee T: Measuring the workload of the anesthesiologist. Anesthesia and Analgesia 71:354-361, 1990
The original study applying standard human factors techniques to measure mental workload to anesthesiologists during actual clinical care. This was the forerunner of many studies listed below.

Sowb YA, Loeb RG. Cognitive analysis of intra-operative critical events: A problem-driven approach to aiding clinicians performance. Journal of Cognition, Technology, and Works 4:107-119, 2002.
Blike GT, Cravero J, Sowb YA, Lancaster J, Whalen K. A semi-quantitative method for evaluating the efficacy and safety of pediatric sedation. Pediatrics 2002; SUBMITTED.

Sowb YA, Loeb RG, Smith BE. Clinicians' Management of Patient's Inspired Oxygen Concentration (FIO2). Anesthesia & Analgesia 2002; SUBMITTED.

Also on this theme:

Weinger MB, Herndon OW, Zornow MH, Paulus MP, Gaba DM, Dallen LT: An objective methodology for task analysis and workload assessment in anesthesia providers. Anesthesiology 80:77-92, 1994

Botney R, Gaba DM: Human factors in monitoring. In Monitoring in Anesthesia and Critical Care, 3rd edition, edited by Blitt CD, Hines RL. New York: Churchill Livingstone, 1994, pp. 23-54.

Paté-Cornell ME, Murphy DL, Lakats LM, Gaba DM: Patient risk in anesthesia: Probabilistic risk analysis and management improvements. Annals of Operations Research 67: 211-233, 1996

Weinger MB, Herndon OW, Gaba DM: The effect of electronic record keeping and transesophageal echocardiography on task distribution, workload, and vigilance during cardiac anesthesia. Anesthesiology 87:144-155, 1997.

Pate-Cornell ME, Lakats LM, Murphy DM, Gaba DM: Anesthesia patient risk: a quantitative approach to organizational factors and risk management options. Risk Anal 17:511-523, 1997.

Sowb YA, Loeb RG, Smith BE. Cognitive Performance During Simulated Ventilation-Related Events (abstract). Anesthesiology 1997; A943.

Kaegi DM, Halamek LP, Dubin A, Howard SK. Heart rate variability as a marker for workload during neonatal resuscitation (abstract) Pediatrics 1998;102,3:Suppl 766-7.

Sowb YA, Loeb RG. Identification of Cognitive Demands With A Competence Model (abstract). Anesth Analg 1998; 86:S188.

Sowb YA, Loeb RG, Moore PG. Competence Analysis of Intraoperative Critical Events (abstract). Anesth Analg 1998; 86:S189

Sowb YA, Loeb RG, Smith B. Clinicians' Response to Management of the Gas Delivery System. Presented at the 1999 Society for Technology in Anesthesia meeting, San Diego, CA.

Kaegi DM, Halamek LP, Van Hare GF, Howard SK, Dubin AM. Effect of mental stress on heart rate variability: Validation of virtual operating and delivery room training modules. Society for Pediatric Research. San Francisco, CA. May 1, 1999.

THEME: Artificial Intelligence and Automation in Health Care

Gaba DM: Automation in anesthesiology. In Human Performance in Automated Systems: Current Research and Trends, edited by Mouloua M, Parasuraman R. Hillsdale, NJ: Lawrence Erlbaum Associates, 1994, pp. 57-63.
An important summary of potential problems with automation in anesthesiology and other dynamic domains, applying lessons learned from automation in aviation and other industries

Also on this theme:

Cook RI, Woods DD, Howie MB, Harrow JC, Gaba DM: Unintentional delivery of vasoactive drugs with an electromechanical infusion device. J Cardiothoracic and Vascular Anesthesia 6:238-244, 1992

Suermondt HJ, Howard SK, Gaba DM, Cooper GF: Effects of decision support on diagnostic accuracy. Anesthesiology 77: A560, 1992

Howard SK: Failure of an automated non-invasive blood pressure device: the contribution of human error and software design flaw. J Clin Monit 9: 232, 1993

Gaba DM: Artificial intelligence and expert systems. In Control and Automation in Anaesthesia, edited by Schwilden H, Stoeckel H. Berlin: Springer, 1995, pp. 22-38.

Gaba DM: General methods of control and automation. In Anesthesia: Implications for the Coming Century, edited by Ikeda K, Kazama T, Katoh T, Doi M, Takahashi H. Tokyo: Churchill Livingstone Japan, 1996, pp 89-97.

Larsson, JE, Hayes-Roth B, Gaba DM, Goals and Functions of the Human Body: An MFM Model for Fault Diagnosis, IEEE Transactions on Systems, Man, and Cybernetics, 27:758-764, 1997.

Larsson JE, Hayes-Roth B, Gaba DM, Smith BE: Evaluation of a medical diagnosis system using simulator test scenarios. Artif Intell Med. 11:119-140, 1997.

Bibliography (Steven K. Howard, M.D.)

Articles:

Howard SK, Gaba DM, Rosekind MR, Zarcone VP: Excessive Daytime Sleepiness In Resident Physicians: Risks, Intervention, And Implications. Acad Med 77:1019-1025, 2002

Gaba DM, Howard SK: Fatigue among clinicians and the safety of patients. New Engl J Med 347:1249-1255, 2002

Howard SK, Rosekind MR, Katz JD, Berry AJ. Fatigue in Anesthesia: Implications and Strategies for Patient and Provider Safety. Anesthesiology 97:1281–94, y 2002;

Howard SK, Gaba DM, Smith BE, Weinger MB, Herndon C, Keshavacharya S, Rosekind MR: Simulation study of rested versus sleep deprived anesthesiologists. Anesthesiology, 2002, IN PRESS

Gaba DM, Howard SK: Conference on human error in anesthesia (meeting report). Anesthesiology 75:553-554, 1991

Gaba DM, Howard SK, Jump B: Production pressure in the work environment: California anesthesiologists attitudes and experiences. Anesthesiology 488-500, 1994

Gaba DM, Howard SK, Small SD: Situation awareness in anesthesiology. Human Factors (Special Issue on Health Care), 1995.

Abstracts: