Table 3 Three Examples of re-established SA

16

“The nurse brings red blood cell [RBC] concentrate into the OR. During check we noticed that the RBC data sheet does not match the patient (same blood group, wrong patient). […] The nurse had to care for too many OR so that she did not check for patient’s name.”

Although the mismatch had been identified just before transfusion, the reporting individual claims that there was a failure to perceive important data when taking the RBCs out of the fridge (SA-I). According to the report, this was caused by excessive workload. Another check prevented from possibly negative consequences.

17

“Intubation with a double-lumen tube after visualizing the glottis. During bag ventilation, no end-tidal CO ₂ was measured. Assuming bronchial obstruction, forceful attempts to inflate the lungs results in small oscillations of the CO ₂ curve. […] Bronchoscopy by the attending called in reveals esophageal intubation. Meanwhile, SpO ₂ had dropped. A single-lumen tube was placed for oxygenation and after a few minutes, this was replaced by a double-lumen tube using tracheal tube introducer without problems.”

After a normal intubation, there is no end-tidal CO₂. As this combination of basic data is contradicting (and therefore not comprehended, SA-II), a re-evaluation including the search for additional information (bronchoscopy) is prompted (SA-I) with the aim for understanding the situation.

After getting SA on the comprehension level (SA-II), the anesthesiologist decides to preferably use a single-lumen tube for safe oxygenation in order to avoid on-going intubation difficulties (SA-III).

18

[…] Due to respiratory distress, the patient was intubated. […] During a transport for CT scan of the thorax, the patient became haemodynamically unstable requiring an increasing dosage of noradrenaline. The initial scan showed pneumothorax corresponding to the clinical assessment. There was the indication for placing a drain quickly. During puncture, the patient developed a haemodynamically highly relevant tension pneumothorax (HR > 180 bpm, blood pressure 90/40 with noradrenaline). Unfortunately, the needles available were not sufficiently long and thick. Therefore air was removed using a drain. Afterwards the blood pressure stabilized but tachycardia remained, later on switching to ventricular tachycardia. On the code-blue trolley there was only an automated external defibrillator so that for cardioversion a defibrillator had to be retrieved from an ICU several floors above. The sinus rhythm, achieved thereby, improved the situation significantly […].

In face of deteriorating vital parameters, the team realizes that a pneumothorax is the most probable cause following the result of the initial scan. Before the puncture, additional basic information is collected by a clinical assessment (assumingly auscultation) to confirm the diagnosis.

After successful puncture, the basic data (vital parameters) change favorably but do not reach normal values. After integrating additional basic information on the monitor (the ECG waveform), the diagnosis of a ventricular tachycardia (SA level II) is made and the need for cardioversion is recognized (decision-making). As the AED is not suitable for cardioversion (long-term memory content), the team decides to retrieve a defibrillator from elsewhere.