Transcript
Managing Threat and Errorin
MedicineRobert Helmreich, PhD
University of Texas Human Factors Research ProjectThe University of Texas at Austin
Texas Hospital Association
Austin
August 1, 2002
The Institute of Medicine Report
‘To Error is Human’ recommended adapting aviation’s approaches to safety and error management
The University of Texas research group is active in both aviation and medicine
Why look for answers from aviation?
• The operating room is not a cockpit
• Medicine is more complex
Medicine and Aviation
• Safety is primary goal
– But cost drives decisions
• Technological innovation
• Multiple sources of threat
• Second guessing after disaster
– Air crashes
– Sentinel events
• Teamwork is essential
Error is Inevitable Because of Human Limitations
• Limited memory capacity
• Limited mental processing capacity
• Negative effects of stress – Tunnel vision
• Negative influence of fatigue and other physiological factors
• Cultural effects
• Flawed teamwork
In both aviation and medicine, people must cope with technology
Newer technology doesn’t eliminate error
Nor does even newer technology
Why Teamwork Matters
• Most endeavors in medicine, science, and industry require groups to work together effectively
• Failures of teamwork in complex organizations can have deadly effects
• More than 2/3 of air crashes involve human error, especially failures in teamwork
• Professional training focuses on technical, not interpersonal, skills
Patient
Nurses/Doctors
Organizational/Professional Cultures
MedicalSystem Influences
SupportStaff
Aircraft
Flight Crew
Organizational/Professional Cultures
AviationSystem Influences
SupportActivities
Physical Environment Physical Environment
Revisiting Aviation and Medicine
3 Cultures – National, Organizational, Professional
• Culture influences how juniors relate to their seniors
• Culture influences how information is shared
• Culture influences attitudes regarding stress and personal capabilities
• Culture influences adherence to rules
• Culture influences interaction with computers and technology
Professional Culture
• Pilots and doctors have a strong professional culture with positive and negative aspects
• Positive:– Strong motivation to do well– Pride in profession
• Negative:– Training that stresses the need for perfection– Sense of personal invulnerability
Personal Invulnerability
The majority of pilots and doctors in all cultures agree that:• their decision-making is as good in emergencies
as in normal situations• their performance is not affected by personal
problems• they do not make more errors under high stress• true professionals can leave behind personal
problems
Pilots’ and Doctors’ Attitudes
0 10 20 30 40 50 60 70 80 90 100
Pilot Doctor
Decision as good inemergencies as normal
Effective pilot/doctor canleave behind personal problems
Performance the same with inexperienced team
Perform effectively whenfatigued
%
Threat
Expected Events and Risks
Patient conditionStaff support
Environmental conditions
Unexpected Events and Risks
Patient conditionStaffing
Equipment failure/availability
External ErrorDrugs
LaboratoryPatient diagnosis
Threats in MedicineEvents and errors outside the individual or team
that require active management for safety
OrganizationalCulture
SchedulingStaffing
Error policyEquipment
SystemNational culture
Health-care policyMedical coverage
ProfessionalProficiency
FatigueMotivation
Culture(Invulnerability)
Proficiency in Aviation
• In addition to initial competency qualification, airline pilots must re- qualify annually
• Airline pilots are strictly limited in terms of flight time – 8 hours in one day, 30 hours in one week, 100 hours in one month, 1,000 hours per year
• Fatigue is still considered a significant problem
New Rules from ACGME
• Accredition Counsel for Graduate Medical Education 7/2003
• 24 hours in 1 shift
• 80 hours in 1 week
• No limit for month or year
Fatigue as Threat
• 24 hours of sleep deprivation have performance effects comparable to a blood alcohol content of 0.1%
• Drew Dawson – Nature, 1997
What Effect Will ACGME Have?
• Non-compliance?• Libby Zion case in NY
• Health costs?
• Lawyers’ picnic?
• Reduction in error?
Error
Typology of Observable Team Error
1. Task Execution – Unintentional physical act that deviates from intended course of action
2. Procedural – Unintentional failure to follow mandated procedures
3. Communication – Failure to transmit information, failure to understand information, failure to share mental model
4. Decision – Choice of action unbounded by procedures that unnecessarily increase risk
5. Violations – Intentional non-compliance with formal procedures or regulations
Decision Error
• Decision that increases risk in a situation with:– Multiple courses of action possible– Time available to evaluate alternatives – No discussion of consequences of
alternate courses of action– No formal procedures to follow
Violations
• 40% of accidents in global aviation fatal accident database had violations
Flight Safety Foundation: Approach and Landing Accident Reduction Task Force Report
R. Khatwa & R. HelmreichNovember, 1998
Males commit violations at a rate 1.4 times that of females
James Reason (1998)
Who violates?
Cross-cultural research shows that American pilots are least
accepting of the need to comply with SOPs.
Helmreich & Merritt (1998)
Violators pose more risk!
Those who violate one or more timesmake 1.7 times more non-violationerrors than those who do not!
UT aviation data
Team processes are both sources of error and defenses against threat and error
Authority Impedes Communication
• Junior staff is unwilling to question the actions of seniors– Refrain from speaking up when errors are observed
• Nurses say nothing when anesthesiologist dozes
• Communication from junior to senior is indirect (and, hence, not understood)– Indirect communication from junior surgeon who
sees senior neurosurgeon about to operate on wrong side of brain
– Co-pilot who reads aloud from manual instead of warning captain that aircraft will run out of fuel and crash
Antidotes toThreat and Error
Optimize Input Factors
• Individual– Qualification and recurrent
qualification– Training in human factors
• Organizational– Culture and communication– Procedures– Policies toward error– Collect meaningful data
Procedures
• Standard Operating Procedures (SOP) were aviation’s first countermeasures against threat and error
• Aviation is arguably over-proceduralized– Tombstone regulation
• Medicine is under-proceduralized– Example: Checklists are critical error
countermeasures
Training in Threat and ErrorCountermeasures:
Crew Resource Management (CRM)
CRM
• CRM training has evolved through 6
generations from psychobabble management
training to threat and error management
integrated with traditional “stick and rudder”
training
• It focuses on teamwork and communications
• It is being extended into space-flight, nuclear,
maritime domains – and medicine
Training Issues in Threatand Error Management
• Human limitations as sources of error
• The nature of error and error management
• Culture and communications
• Expert decision-making
• Training in using specific behaviors and procedures as countermeasures against threat and error– Briefings– Inquiry– Sharing mental models– Conflict resolution– Fatigue and alertness management
• Analysis of positive teamwork and adverse and sentinel events
CRM as Countermeasures
CRM Skills
Error Management
Error Avoidance
Threat Management
Undesired Patient State Management
Sixth Generation CRM
A focus of CRM is sharing one’s mental model - common
understandingof the situation
What Can an Organization Do?
• Define a clear policy regarding human error
• Proceduralize where appropriate
• Recognize the dangers in fatigue
• Use protected confidential reporting systems to uncover threats
• Provide formal training in threat and error management
Lessons I Have Learned
• Basic medical education should include human factors, human limitations, and human error
• Safety initiatives must reflect and address organizational and professional cultures
• Culturally relevant team training can enhance safety
• Medicine has a long way to go
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