Background: Clinical reviews of foetal deaths and babies born in poor condition, found that in 75 percent of cases, cardiotocographs (CTG) were implicated (CESDI 1997 – 2008). Poor skills in CTG interpretation; communicating the decisions; and urgency of the situation, were identified. This research is looking at how the brain works with regard to interpreting and acting on CTGs and the potential error pathways and adequate interpretation of CTGs is seen as crucial to quality improvement and the reduction of medico-legal risk.
Methods: A hierarchical task analysis (Shepherd, 1998) (HTA) and a cognitive task analysis (CTA) was undertaken in the Day Assessment Unit (DAU) of a maternity hospital to identify the key technical and cognitive criteria needed to undertake CTG monitoring within an antenatal clinic. All grades of health care professionals (HCPs) were interviewed in order to validate the HTA and CTA data. A Quantitative Analysis of Situation Awareness (Edgar & Edgar, 2008) (QASA) was developed from this information, involving twenty statements of true/false with a confidence scale of one to four, regarding belief that they completed a task, was carried out as an observational checklist. Twenty-five observations of HCPs using CTGs, monitoring consented women, within a normal antenatal clinic in a DAU were undertaken using a QASA and CTA questionnaire. Directly the observation was completed, the HCP completed an identical QASA and had a five minute interview, based on the CTA prompt questions (involving decisions, pattern recognition, interferences, attention and biases and heuristics). The two QASAs were compared to see if the observed actions matched the reported ones, reporting their level of confidence in their reported statements.
Results: The QASA was analysed: 104/500 errors (20.8%) were found. A Pearson correlation was undertaken: loss of situation awareness (Endesley, 1995) SA and increase in errors (p<.000), an increase in information bias and number of phone calls phone calls (p <.025) high confidence leading to low SA (p<.007). A rotational factor analysis identified seven components (significant with Eigenvalues of >1): SA; errors; information bias; phone calls and confidence, standard operating procedures for undertaking a CTG and when interacting with women patients.
Conclusion: Evidence suggests that information bias is high, and as errors increase, confidence that their recall is correct increases. This has implications for reviewing case notes and critical incidents and potentially in the care received during pregnancy. Further research is ongoing into pattern recognition, information bias and the decision-making techniques used when dealing with CTG interpretation and reporting.
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