Cognitive Analysis of Intraoperative Critical Events: A Problem-Driven Approach to Aiding Clinicians’ Performance*

Human error is responsible for a large proportion of the anaesthesia mishaps that occur annually in the United States. Ventilation-related events (VRE) constitute a significant number of anaesthesia critical incidents. Monitoring equipment and their displays extend anaesthesiologists’ resources during VRE but at the expense of additional cognitive demands. This project is a cognitive analysis of intraoperative (inside the operating room) VRE. Goal–means networks were utilised to build a problem-solving model of clinicians’ management of patients’ ventilation during anaesthesia and to map the demands of VRE. The model was also used to identify challenging VRE that were then simulated using a comprehensive anaesthesia simulator. The response of eight experienced clinicians was captured on videotape and analysed to investigate the effectiveness of medical equipment in supporting clinical decision making during VRE.