465.ppt

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