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    1. 1. Managing Threat and Error in Medicine Robert L. Helmreich, PhD,Robert L. Helmreich, PhD, FRAeSFRAeS American Society ofAmerican Society of Safety EngineersSafety Engineers Atlanta, March 13, 2003Atlanta, March 13, 2003 Human Factors Research ProjectHuman Factors Research Project The University of Texas at AustinThe University of Texas at Austin
    2. 2. UT Human Factors ResearchUT Human Factors Research ProjectProject Support from:Support from:  Federal Aviation AdministrationFederal Aviation Administration  Agency for Healthcare Research and QualityAgency for Healthcare Research and Quality  Applying aviation safety approaches to medicineApplying aviation safety approaches to medicine  NASANASA  Daimler-Benz FoundationDaimler-Benz Foundation  American College of SurgeonsAmerican College of Surgeons  Kaiser-Permanente HMOKaiser-Permanente HMO
    3. 3. Medicine and AviationMedicine and Aviation  Safety is primary goalSafety is primary goal – But cost drives decisionsBut cost drives decisions  Technological innovationTechnological innovation  Multiple sources of threatMultiple sources of threat  Second guessing after disasterSecond guessing after disaster – Air crashesAir crashes – Sentinel eventsSentinel events  Teamwork is essentialTeamwork is essential
    4. 4. Error is Inevitable Because ofError is Inevitable Because of Human LimitationsHuman Limitations  Limited memory capacityLimited memory capacity  Limited mental processing capacityLimited mental processing capacity  Negative effects of stressNegative effects of stress – Tunnel visionTunnel vision  Negative influence of fatigue and otherNegative influence of fatigue and other physiological factorsphysiological factors  Cultural effectsCultural effects  Flawed teamworkFlawed teamwork
    5. 5. Journalists can sensationalize error! Journalists can sensationalize error!
    6. 6. In both aviation and medicine, peopleIn both aviation and medicine, people must cope with technologymust cope with technology
    7. 7. Newer technology doesn’tNewer technology doesn’t eliminate erroreliminate error
    8. 8. Nor does even newer technologyNor does even newer technology
    9. 9. Threats in AviationThreats in Aviation
    10. 10. Overt ThreatsOvert Threats  Adverse weatherAdverse weather  TerrainTerrain  TrafficTraffic  Airport conditionsAirport conditions  A/C malfunctionsA/C malfunctions  AutomationAutomation eventsevents  CommunicationCommunication eventsevents  Operational time pressuresOperational time pressures  Non-normal operationsNon-normal operations  ATC commands / errorsATC commands / errors  Cabin events / errorsCabin events / errors  MX events / errorsMX events / errors  Dispatch events / errorsDispatch events / errors  Ground crew events / errorsGround crew events / errors
    11. 11. Latent ThreatsLatent Threats  Factors not directly linked to observableFactors not directly linked to observable threat and error that increase risk and thethreat and error that increase risk and the probability of errorprobability of error  Crew management of latent threats isCrew management of latent threats is difficult because they are not immediatelydifficult because they are not immediately visiblevisible  Latent threat identification is key toLatent threat identification is key to accident and incident analysisaccident and incident analysis
    12. 12. Latent Threat ExamplesLatent Threat Examples  Inadequate management oversightInadequate management oversight  Inadequate regulatory oversightInadequate regulatory oversight  Flawed proceduresFlawed procedures  Organizational culture and climateOrganizational culture and climate  Scheduling and rostering practicesScheduling and rostering practices  Crew fatigueCrew fatigue  Performance assessment practicesPerformance assessment practices  Inadequate accident and incidentInadequate accident and incident investigationinvestigation
    13. 13. Representative Threat Findings:Representative Threat Findings: Data from Observations in 12Data from Observations in 12 AirlinesAirlines  90% of flights had one or more threats90% of flights had one or more threats  Organizational range – 84% to 97%Organizational range – 84% to 97%  Most frequent threatsMost frequent threats  Adverse weather – 19%Adverse weather – 19%  ATC clearances/late changes 16%ATC clearances/late changes 16%
    14. 14. Why Teamwork MattersWhy Teamwork Matters  Most endeavors in medicine, science, andMost endeavors in medicine, science, and industry require groups to work togetherindustry require groups to work together effectivelyeffectively  Failures of teamwork in complex organizationsFailures of teamwork in complex organizations can have deadly effectscan have deadly effects  More than 2/3 of air crashes involve humanMore than 2/3 of air crashes involve human error, especially failures in teamworkerror, especially failures in teamwork  Professional training focuses on technical, notProfessional training focuses on technical, not interpersonal, skillsinterpersonal, skills
    15. 15. 3 Cultures – National,3 Cultures – National, Organizational, ProfessionalOrganizational, Professional  Culture influences how juniors relate to theirCulture influences how juniors relate to their seniorsseniors  Culture influences how information isCulture influences how information is sharedshared  Culture influences attitudes regardingCulture influences attitudes regarding stress and personal capabilitiesstress and personal capabilities  Culture influences adherence to rulesCulture influences adherence to rules  Culture influences interaction withCulture influences interaction with computers and technologycomputers and technology
    16. 16. Professional CultureProfessional Culture  Pilots and doctors have a strong professionalPilots and doctors have a strong professional culture with positive and negative aspectsculture with positive and negative aspects  Positive:Positive: – Strong motivation to do wellStrong motivation to do well – Pride in professionPride in profession  Negative:Negative: – Training that stresses the need for perfectionTraining that stresses the need for perfection – Sense of personal invulnerabilitySense of personal invulnerability
    17. 17. Personal InvulnerabilityPersonal Invulnerability The majority of pilots and doctors in all culturesThe majority of pilots and doctors in all cultures agree that:agree that:  their decision-making is as good in emergenciestheir decision-making is as good in emergencies as in normal situationsas in normal situations  their performance is not affected by personaltheir performance is not affected by personal problemsproblems  they do not make more errors under high stressthey do not make more errors under high stress  true professionals can leavetrue professionals can leave behind personalbehind personal problemsproblems
    18. 18. Pilots’ and Doctors’ AttitudesPilots’ and Doctors’ Attitudes 0 10 20 30 40 50 60 70 80 90 100 Pilot Doctor 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 %
    19. 19. Threat in medicineThreat in medicine
    20. 20. 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)
    21. 21. Fatigue as ThreatFatigue as Threat  24 hours of sleep deprivation have24 hours of sleep deprivation have performance effects comparable to aperformance effects comparable to a blood alcohol content of 0.1%blood alcohol content of 0.1%  Drew Dawson –Drew Dawson – Nature, 1997Nature, 1997  US resident shifts may exceed 100hrsUS resident shifts may exceed 100hrs  Fatigue may be the greatest source ofFatigue may be the greatest source of error in medicine (US and many othererror in medicine (US and many other countries – excluding Denmarkcountries – excluding Denmark))
    22. 22. Threats to Safety in the ORThreats to Safety in the OR  ProficiencyProficiency  FatigueFatigue  Flawed group dynamicsFlawed group dynamics  LeadershipLeadership  Unexpected patient reactionUnexpected patient reaction
    23. 23. ErrorError
    24. 24. CFIT: Controlled Flight into TrainCFIT: Controlled Flight into Train
    25. 25. 44,000-98,000 deaths/year due44,000-98,000 deaths/year due to medical errorto medical error - IOM Report- IOM Report ““Deaths Due to Medical Errors Are ExaggeratedDeaths Due to Medical Errors Are Exaggerated in Institute of Medicine Report”in Institute of Medicine Report” -McDonald et. Al., JAMA 5 Jul 2000-McDonald et. Al., JAMA 5 Jul 2000 ““Institute of Medicine Medical Error Figures AreInstitute of Medicine Medical Error Figures Are NotNot Exaggerated”Exaggerated” - Leape, JAMA 5 Jul 2000- Leape, JAMA 5 Jul 2000
    26. 26. Typology of Observable Team ErrorTypology of Observable Team Error 1. Task Execution1. Task Execution –– Unintentional physical act thatUnintentional physical act that deviates from intended course of actiondeviates from intended course of action 2. Procedural2. Procedural –– Unintentional failure to follow mandatedUnintentional failure to follow mandated proceduresprocedures 3. Communication3. Communication – Failure to transmit information,– Failure to transmit information, failure to understand information, failure to share mentalfailure to understand information, failure to share mental modelmodel 4. Decision4. Decision – Choice of action unbounded by procedures– Choice of action unbounded by procedures that unnecessarily increase riskthat unnecessarily increase risk 5. Intentional Noncompliance5. Intentional Noncompliance – Violations of formal– Violations of formal procedures or regulationsprocedures or regulations
    27. 27. Decision ErrorDecision Error  Decision that increases risk in a situation with:Decision that increases risk in a situation with: – Multiple courses of action possibleMultiple courses of action possible – Time available to evaluate alternativesTime available to evaluate alternatives – No discussion of consequences of alternateNo discussion of consequences of alternate courses of actioncourses of action – No formal procedures to followNo formal procedures to follow
    28. 28. Maintaining Competence in AviationMaintaining Competence in Aviation  In addition to initial competencyIn addition to initial competency qualification, airline pilots must re-qualification, airline pilots must re- qualify annuallyqualify annually  Airline pilots are strictly limited in termsAirline pilots are strictly limited in terms of flight time – 8 hours in one day, 30of flight time – 8 hours in one day, 30 hours in one week, 100 hours in onehours in one week, 100 hours in one month, 1,000 hours per yearmonth, 1,000 hours per year
    29. 29. Conceptual Framework of ourConceptual Framework of our ProjectProject  The University of Texas Threat and ErrorThe University of Texas Threat and Error Management Model – developed inManagement Model – developed in aviation and being adapted to medicineaviation and being adapted to medicine An empirically derived model of howAn empirically derived model of how professionals deal with latent and overtprofessionals deal with latent and overt threats in their operating environments andthreats in their operating environments and the inevitable errors that occurthe inevitable errors that occur
    30. 30. Threat and Error Management ModelThreat and Error Management Model T h r e a t s : L a t e n t a n d O v e r t T h r e a t M a n a g e m e n t I n c o n s e q u e n t i a l I n c i d e n t / A c c i d e n t E r r o r s E r r o r M a n a g e m e n t U n d e s i r e d A i r c r a f t S t a t e U n d e s i r e d A i r c r a f t S t a t e M a n a g e m e n t
    31. 31. Use of the ModelUse of the Model  International Air Transport AssociationInternational Air Transport Association using to classify all air accidentsusing to classify all air accidents worldwideworldwide  Continental Airlines using to classify allContinental Airlines using to classify all incident reportsincident reports  Being implemented as framework for near-Being implemented as framework for near- miss reporting system at UT hospitalsmiss reporting system at UT hospitals
    32. 32. Team Processes Are BothTeam Processes Are Both Sources of Error and DefensesSources of Error and Defenses Against Threat and ErrorAgainst Threat and Error
    33. 33. Authority ImpedesAuthority Impedes CommunicationCommunication  Junior staff is unwilling to question the actions of seniorsJunior staff is unwilling to question the actions of seniors – Refrain from speaking up when errors are observedRefrain from speaking up when errors are observed  Nurses say nothing when anesthesiologist dozesNurses say nothing when anesthesiologist dozes  Communication from junior to senior is indirect (and,Communication from junior to senior is indirect (and, hence, not understood)hence, not understood) – Indirect communication from junior surgeon who sees seniorIndirect communication from junior surgeon who sees senior neurosurgeon about to operate on wrong side of brainneurosurgeon about to operate on wrong side of brain – Co-pilot who reads aloud from manual instead of warningCo-pilot who reads aloud from manual instead of warning captain that aircraft will run out of fuel and crashcaptain that aircraft will run out of fuel and crash
    34. 34. Antidotes toAntidotes to Threat and ErrorThreat and Error
    35. 35. Safety Requires DataSafety Requires Data  Surveys/interviews of front-lineSurveys/interviews of front-line personnelpersonnel  Non-jeopardy observations of normalNon-jeopardy observations of normal behavior (e.g., OR)behavior (e.g., OR)  Analysis of adverse and sentinelAnalysis of adverse and sentinel events, near misses, and successesevents, near misses, and successes  Confidential incident reporting systemsConfidential incident reporting systems
    36. 36. ProceduresProcedures  Standard Operating Procedures (SOP)Standard Operating Procedures (SOP) were aviation’s first countermeasureswere aviation’s first countermeasures against threat and erroragainst threat and error  Aviation is arguably over-proceduralizedAviation is arguably over-proceduralized – Tombstone regulationTombstone regulation  Medicine is under-proceduralizedMedicine is under-proceduralized – Example: Checklists are critical errorExample: Checklists are critical error countermeasurescountermeasures
    37. 37. Training in Threat and ErrorTraining in Threat and Error Countermeasures:Countermeasures: Crew Resource ManagementCrew Resource Management (CRM)(CRM)
    38. 38. CRMCRM  CRM training has evolved through 6 generationsCRM training has evolved through 6 generations from psychobabble management training tofrom psychobabble management training to threat and error management integrated withthreat and error management integrated with traditional “stick and rudder” trainingtraditional “stick and rudder” training  It focuses on teamwork and communicationsIt focuses on teamwork and communications  It is being extended into space-flight, nuclear,It is being extended into space-flight, nuclear, maritime domains – and medicinemaritime domains – and medicine
    39. 39. An Expanded Definition of CRMAn Expanded Definition of CRM CRM Skills Error Management Error Avoidance Threat Management Undesired Aircraft State Management Sixth Generation CRM
    40. 40. Training Issues in ThreatTraining Issues in Threat and Error Managementand Error Management  Human limitations as sources of errorHuman limitations as sources of error  The nature of error and error managementThe nature of error and error management  Culture and communicationsCulture and communications  Expert decision-makingExpert decision-making  Training in using specific behaviors and procedures asTraining in using specific behaviors and procedures as countermeasures against threat and errorcountermeasures against threat and error – BriefingsBriefings – InquiryInquiry – Sharing mental modelsSharing mental models – Conflict resolutionConflict resolution – Fatigue and alertness managementFatigue and alertness management  Analysis of positive teamwork and adverse and sentinelAnalysis of positive teamwork and adverse and sentinel eventsevents
    41. 41. Lessons I Have LearnedLessons I Have Learned  Basic medical education should include humanBasic medical education should include human factors, human limitations, and human errorfactors, human limitations, and human error  Safety initiatives must reflect and addressSafety initiatives must reflect and address organizational and professional culturesorganizational and professional cultures  Culturally relevant team training can enhanceCulturally relevant team training can enhance safetysafety  Organizations need a clear policy regarding errorOrganizations need a clear policy regarding error  Tolerant of unintentional error but not violationsTolerant of unintentional error but not violations  Medicine has a long way to goMedicine has a long way to go
    42. 42. The University of TexasThe University of Texas Human Factors Research ProjectHuman Factors Research Project www.psy.utexas.edu/HumanFactors