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  • 1. Managing Threat and Error in Medicine Robert Helmreich, PhD University of Texas Human Factors Research Project The University of Texas at Austin Texas Hospital Association Austin August 1, 2002
  • 2.
    • 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
  • 3.
    • Why look for answers from aviation?
      • The operating room is not a cockpit
      • Medicine is more complex
  • 4. 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
  • 5. 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
  • 6.
    • In both aviation and medicine, people must cope with technology
  • 7.  
  • 8. Newer technology doesn’t eliminate error
  • 9.  
  • 10. Nor does even newer technology
  • 11.  
  • 12. 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
  • 13. Revisiting Aviation and Medicine Patient Nurses/ Doctors Organizational/ Professional Cultures Medical System Influences Support Staff Aircraft Flight Crew Organizational/ Professional Cultures Aviation System Influences Support Activities Physical Environment Physical Environment
  • 14. 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
  • 15. 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
  • 16. 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
  • 17. Pilots’ and Doctors’ Attitudes Decision as good in emergencies as normal Effective pilot/doctor can leave behind personal problems Performance the same with inexperienced team Perform effectively when fatigued %
  • 18. Threat
  • 19. Expected Events and Risks Patient condition Staff support Environmental conditions Unexpected Events and Risks Patient condition Staffing Equipment failure/availability External Error Drugs Laboratory Patient diagnosis Threats in Medicine Events and errors outside the individual or team that require active management for safety Organizational Culture Scheduling Staffing Error policy Equipment System National culture Health-care policy Medical coverage Professional Proficiency Fatigue Motivation Culture (Invulnerability)
  • 20. 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
  • 21. 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
  • 22. Fatigue as Threat
    • 24 hours of sleep deprivation have performance effects comparable to a blood alcohol content of 0.1%
            • Drew Dawson – Nature, 1997
  • 23. What Effect Will ACGME Have?
    • Non-compliance?
      • Libby Zion case in NY
    • Health costs?
    • Lawyers’ picnic?
    • Reduction in error?
  • 24. Error
  • 25. 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
  • 26. 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
  • 27. 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. Helmreich November, 1998
  • 28. Males commit violations at a rate 1.4 times that of females James Reason (1998) Who violates?
  • 29. Cross-cultural research shows that American pilots are least accepting of the need to comply with SOPs. Helmreich & Merritt (1998)
  • 30. Violators pose more risk! Those who violate one or more times make 1.7 times more non-violation errors than those who do not! UT aviation data
  • 31. Team processes are both sources of error and defenses against threat and error
  • 32. 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
  • 33. Antidotes to Threat and Error
  • 34. Optimize Input Factors
    • Individual
      • Qualification and recurrent qualification
      • Training in human factors
    • Organizational
      • Culture and communication
      • Procedures
      • Policies toward error
      • Collect meaningful data
  • 35. 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
  • 36. Training in Threat and Error Countermeasures: Crew Resource Management (CRM)
  • 37. 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
  • 38. Training Issues in Threat and 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
  • 39. CRM as Countermeasures Sixth Generation CRM CRM Skills Error Management Error Avoidance Threat Management Undesired Patient State Management
  • 40. A focus of CRM is sharing one’s mental model - common understanding of the situation
  • 41.  
  • 42. 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
  • 43. 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
  • 44.