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    611.ppt 611.ppt Presentation Transcript

    • Managing Threat and Error in Medicine Robert L. Helmreich, PhD, FRAeS American Society of Safety Engineers Atlanta, March 13, 2003 Human Factors Research Project The University of Texas at Austin
    • UT Human Factors Research Project
      • Support from:
      • Federal Aviation Administration
      • Agency for Healthcare Research and Quality
        • Applying aviation safety approaches to medicine
      • NASA
      • Daimler-Benz Foundation
      • American College of Surgeons
      • Kaiser-Permanente HMO
    • 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
      • Journalists can sensationalize error!
      • In both aviation and medicine, people must cope with technology
    • Newer technology doesn’t eliminate error
    • Nor does even newer technology
    • Threats in Aviation
    • Overt Threats
      • Adverse weather
      • Terrain
      • Traffic
      • Airport conditions
      • A/C malfunctions
      • Automation events
      • Communication events
      • Operational time pressures
      • Non-normal operations
      • ATC commands / errors
      • Cabin events / errors
      • MX events / errors
      • Dispatch events / errors
      • Ground crew events / errors
    • Latent Threats
      • Factors not directly linked to observable threat and error that increase risk and the probability of error
      • Crew management of latent threats is difficult because they are not immediately visible
      • Latent threat identification is key to accident and incident analysis
    • Latent Threat Examples
      • Inadequate management oversight
      • Inadequate regulatory oversight
      • Flawed procedures
      • Organizational culture and climate
      • Scheduling and rostering practices
      • Crew fatigue
      • Performance assessment practices
      • Inadequate accident and incident investigation
    • Representative Threat Findings: Data from Observations in 12 Airlines
      • 90% of flights had one or more threats
      • Organizational range – 84% to 97%
      • Most frequent threats
        • Adverse weather – 19%
        • ATC clearances/late changes 16%
    • 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
    • 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 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 %
    • Threat in medicine
    • 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 – Latent and Active 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 Qualification Motivation Culture (Invulnerability)
    • Fatigue as Threat
      • 24 hours of sleep deprivation have performance effects comparable to a blood alcohol content of 0.1%
              • Drew Dawson – Nature, 1997
        • US resident shifts may exceed 100hrs
      • Fatigue may be the greatest source of error in medicine (US and many other countries – excluding Denmark )
    • Threats to Safety in the OR
      • Proficiency
      • Fatigue
      • Flawed group dynamics
      • Leadership
      • Unexpected patient reaction
    • Error
    • CFIT: Controlled Flight into Train
    • 44,000-98,000 deaths/year due to medical error - IOM Report “ Deaths Due to Medical Errors Are Exaggerated in Institute of Medicine Report” -McDonald et. Al., JAMA 5 Jul 2000 “ Institute of Medicine Medical Error Figures Are Not Exaggerated” - Leape, JAMA 5 Jul 2000
    • 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. Intentional Noncompliance – Violations of 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
    • Maintaining Competence 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
    • Conceptual Framework of our Project
      • The University of Texas Threat and Error Management Model – developed in aviation and being adapted to medicine
        • An empirically derived model of how professionals deal with latent and overt threats in their operating environments and the inevitable errors that occur
    • Threat and Error Management Model
    • Use of the Model
      • International Air Transport Association using to classify all air accidents worldwide
      • Continental Airlines using to classify all incident reports
      • Being implemented as framework for near-miss reporting system at UT hospitals
    • 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 to Threat and Error
    • Safety Requires Data
      • Surveys/interviews of front-line personnel
      • Non-jeopardy observations of normal behavior (e.g., OR)
      • Analysis of adverse and sentinel events, near misses, and successes
      • Confidential incident reporting systems
    • 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 Error Countermeasures: 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
    • An Expanded Definition of CRM Sixth Generation CRM CRM Skills Error Management Error Avoidance Threat Management Undesired Aircraft State Management
    • 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
    • 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
      • Organizations need a clear policy regarding error
        • Tolerant of unintentional error but not violations
      • Medicine has a long way to go
    • The University of Texas Human Factors Research Project www.psy.utexas.edu/HumanFactors