Managing Threat and Error in Medicine

Robert L. Helmreich, PhD, Robert L. Helmreich, PhD, FRAeSFRAeS

American Society ofAmerican Society ofSafety EngineersSafety Engineers

Atlanta, March 13, 2003Atlanta, March 13, 2003

Human Factors Research ProjectHuman Factors Research ProjectThe University of Texas at AustinThe University of Texas at Austin

UT Human Factors Research UT 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 medicine Applying aviation safety approaches to medicine NASANASA Daimler-Benz FoundationDaimler-Benz Foundation American College of SurgeonsAmerican College of Surgeons Kaiser-Permanente HMOKaiser-Permanente HMO

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

Error is Inevitable Because of Error is Inevitable Because of Human LimitationsHuman Limitations

Limited memory capacityLimited memory capacity Limited mental processing Limited mental processing

capacitycapacity Negative effects of stress Negative effects of stress

– Tunnel visionTunnel vision Negative influence of fatigue and Negative influence of fatigue and

other physiological factorsother physiological factors Cultural effectsCultural effects Flawed teamworkFlawed teamwork

Journalists can sensationalize error!

Journalists can sensationalize error!

In both aviation and medicine, In both aviation and medicine, people must cope with technologypeople must cope with technology

Newer technology doesn’t Newer technology doesn’t eliminate erroreliminate error

Nor does even newer technologyNor does even newer technology

Threats in AviationThreats in Aviation

Overt ThreatsOvert Threats Adverse weatherAdverse weather TerrainTerrain TrafficTraffic Airport conditionsAirport conditions A/C malfunctionsA/C malfunctions Automation eventsAutomation events Communication eventsCommunication events

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

Latent ThreatsLatent Threats

Factors not directly linked to Factors not directly linked to observable threat and error that observable threat and error that increase risk and the probability of increase risk and the probability of errorerror

Crew management of latent threats Crew management of latent threats is difficult because they are not is difficult because they are not immediately visibleimmediately visible

Latent threat identification is key to Latent threat identification is key to accident and incident analysisaccident and incident analysis

Latent Threat ExamplesLatent Threat Examples Inadequate management oversightInadequate management oversight Inadequate regulatory oversightInadequate regulatory oversight Flawed procedures Flawed 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 incident Inadequate accident and incident

investigationinvestigation

Representative Threat Findings:Representative Threat Findings:Data from Observations in 12 Data from Observations in 12

AirlinesAirlines 90% of flights had one or more 90% of flights had one or more

threatsthreats 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%

Why Teamwork Matters Why Teamwork Matters

Most endeavors in medicine, science, and Most endeavors in medicine, science, and industry require groups to work together industry require groups to work together effectivelyeffectively

Failures of teamwork in complex Failures of teamwork in complex organizations can have deadly effectsorganizations can have deadly effects

More than 2/3 of air crashes involve More than 2/3 of air crashes involve human error, especially failures in human error, especially failures in teamworkteamwork

Professional training focuses on technical, Professional training focuses on technical, not interpersonal, skillsnot interpersonal, skills

3 Cultures – National, 3 Cultures – National, Organizational, ProfessionalOrganizational, Professional

Culture influences how juniors relate to Culture influences how juniors relate to their seniorstheir seniors

Culture influences how information is Culture influences how information is sharedshared

Culture influences attitudes regarding Culture influences attitudes regarding stress and personal capabilitiesstress and personal capabilities

Culture influences adherence to rulesCulture influences adherence to rules Culture influences interaction with Culture influences interaction with

computers and technologycomputers and technology

Professional CultureProfessional Culture Pilots and doctors have a strong Pilots and doctors have a strong

professional culture with positive and professional culture with positive and negative aspectsnegative 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

Personal InvulnerabilityPersonal InvulnerabilityThe majority of pilots and doctors in all cultures The majority of pilots and doctors in all cultures

agree that:agree that: their decision-making is as good in their decision-making is as good in

emergencies as in normal situationsemergencies as in normal situations their performance is not affected by personal their 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 personal behind personal

problemsproblems

Pilots’ and Doctors’ AttitudesPilots’ 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 in Threat in medicinemedicine

Expected Events and Risks

Patient conditionStaff support

Environmental conditions

Unexpected Events and Risks

Patient conditionStaffing

Equipment failure/availability

External ErrorDrugs

LaboratoryPatient diagnosis

Threats – Latent and ActiveEvents and errors outside the individual or team

that require active management for safety

OrganizationalCulture

SchedulingStaffing

Error policyEquipment

SystemNational culture

Health-care policyMedical coverage

ProfessionalQualificationMotivation

Culture(Invulnerability)

Fatigue as ThreatFatigue as Threat

24 hours of sleep deprivation have 24 hours of sleep deprivation have performance effects comparable to performance effects comparable to a blood alcohol content of 0.1%a blood alcohol content of 0.1%

Drew Dawson – Drew Dawson – Nature, 1997Nature, 1997 US resident shifts may exceed US resident shifts may exceed

100hrs100hrs Fatigue may be the greatest source Fatigue may be the greatest source

of error in medicine (US and many of error in medicine (US and many other countries – excluding other countries – excluding DenmarkDenmark))

Threats to Safety in the ORThreats to Safety in the OR

ProficiencyProficiency

FatigueFatigue

Flawed group dynamicsFlawed group dynamics

LeadershipLeadership

Unexpected patient reactionUnexpected patient reaction

ErrorError

CFIT: Controlled Flight into CFIT: Controlled Flight into TrainTrain

44,000-98,000 deaths/year 44,000-98,000 deaths/year due to medical errordue to medical error

- IOM Report- IOM Report

““Deaths Due to Medical Errors Are Deaths Due to Medical Errors Are Exaggerated in Institute of Medicine Exaggerated in Institute of Medicine

Report”Report”-McDonald et. Al., JAMA 5 Jul 2000-McDonald et. Al., JAMA 5 Jul 2000

““Institute of Medicine Medical Error Institute of Medicine Medical Error Figures Are Figures Are NotNot Exaggerated” Exaggerated”

- Leape, JAMA 5 Jul 2000- Leape, JAMA 5 Jul 2000

Typology of Observable Team Typology of Observable Team ErrorError

1. Task Execution1. Task Execution – – Unintentional physical act that deviates Unintentional physical act that deviates from intended course of actionfrom intended course of action

2. Procedural2. Procedural –– Unintentional failure to follow mandated Unintentional failure to follow mandated proceduresprocedures

3. Communication3. Communication – Failure to transmit information, failure to – Failure to transmit information, failure to understand information, failure to share mental modelunderstand information, failure to share mental model

4. Decision4. Decision – Choice of action unbounded by procedures that – Choice of action unbounded by procedures that unnecessarily increase riskunnecessarily increase risk

5. Intentional Noncompliance5. Intentional Noncompliance – Violations of formal – Violations of formal procedures or regulationsprocedures or regulations

Decision ErrorDecision Error

Decision that increases risk in a situation Decision that increases risk in a situation with:with:– Multiple courses of action possibleMultiple courses of action possible– Time available to evaluate alternatives Time available to evaluate alternatives – No discussion of consequences of alternate No discussion of consequences of alternate

courses of actioncourses of action– No formal procedures to followNo formal procedures to follow

Maintaining Competence in Maintaining Competence in AviationAviation

In addition to initial competency In addition to initial competency qualification, airline pilots must re- qualification, airline pilots must re- qualify annuallyqualify annually

Airline pilots are strictly limited in Airline pilots are strictly limited in terms of flight time – 8 hours in one terms of flight time – 8 hours in one day, 30 hours in one week, 100 day, 30 hours in one week, 100 hours in one month, 1,000 hours per hours in one month, 1,000 hours per yearyear

Conceptual Framework of our Conceptual Framework of our ProjectProject

The University of Texas Threat and The University of Texas Threat and Error Management Model – developed Error Management Model – developed in aviation and being adapted to in aviation and being adapted to medicinemedicine

An empirically derived model of how An empirically derived model of how professionals deal with latent and overt professionals deal with latent and overt threats in their operating environments threats in their operating environments and the inevitable errors that occurand the inevitable errors that occur

Threat and Error Management Threat and Error Management ModelModel

Th re ats:Late n t an d Ov e rt

Th re at M an ag e me n t

In co n se q ue n tial In cide n t / Accide n t

Erro rs

Erro r M an age me n t

Un de sire d AircraftState

Un de sire d AircraftState M an age me n t

Use of the ModelUse of the Model

International Air Transport International Air Transport Association using to classify all air Association using to classify all air accidents worldwideaccidents worldwide

Continental Airlines using to classify Continental Airlines using to classify all incident reportsall incident reports

Being implemented as framework for Being implemented as framework for near-miss reporting system at UT near-miss reporting system at UT hospitalshospitals

Team Processes Are Both Team Processes Are Both Sources of Error and Defenses Sources of Error and Defenses

Against Threat and ErrorAgainst Threat and Error

Authority Impedes Authority Impedes CommunicationCommunication

Junior staff is unwilling to question the actions of Junior staff is unwilling to question the actions of seniorsseniors– 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 Communication from junior to senior is indirect (and, hence, not understood)(and, hence, not understood)– Indirect communication from junior surgeon who Indirect communication from junior surgeon who

sees senior neurosurgeon about to operate on wrong sees senior neurosurgeon about to operate on wrong side of brainside of brain

– Co-pilot who reads aloud from manual instead of Co-pilot who reads aloud from manual instead of warning captain that aircraft will run out of fuel and warning captain that aircraft will run out of fuel and crashcrash

Antidotes toAntidotes toThreat and ErrorThreat and Error

Safety Requires DataSafety Requires Data

Surveys/interviews of front-line Surveys/interviews of front-line personnelpersonnel

Non-jeopardy observations of Non-jeopardy observations of normal behavior (e.g., OR)normal behavior (e.g., OR)

Analysis of adverse and sentinel Analysis of adverse and sentinel events, near misses, and successesevents, near misses, and successes

Confidential incident reporting Confidential incident reporting systemssystems

ProceduresProcedures

Standard Operating Procedures (SOP) Standard Operating Procedures (SOP) were aviation’s first countermeasures were aviation’s first countermeasures against threat and erroragainst threat and error

Aviation is arguably over-Aviation is arguably over-proceduralizedproceduralized– Tombstone regulationTombstone regulation

Medicine is under-proceduralizedMedicine is under-proceduralized– Example: Checklists are critical error Example: Checklists are critical error

countermeasurescountermeasures

Training in Threat and ErrorTraining in Threat and ErrorCountermeasures:Countermeasures:

Crew Resource Management Crew Resource Management (CRM)(CRM)

CRMCRM

CRM training has evolved through 6 CRM training has evolved through 6

generations from psychobabble management generations from psychobabble management

training to threat and error management training to threat and error management

integrated with traditional “stick and rudder” integrated with traditional “stick and rudder”

trainingtraining 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 medicine maritime domains – and medicine

An Expanded Definition of An Expanded Definition of CRMCRM

CRM Skills

Error Management

Error Avoidance

Threat Management

Undesired Aircraft State Management

Sixth Generation CRM

Training Issues in ThreatTraining Issues in Threatand 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 as Training 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 sentinel Analysis of positive teamwork and adverse and sentinel eventsevents

Lessons I Have LearnedLessons I Have Learned

Basic medical education should include human Basic medical education should include human factors, human limitations, and human errorfactors, human limitations, and human error

Safety initiatives must reflect and address Safety initiatives must reflect and address organizational and professional culturesorganizational and professional cultures

Culturally relevant team training can enhance Culturally relevant team training can enhance safetysafety

Organizations need a clear policy regarding Organizations need a clear policy regarding errorerror 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

The University of Texas The University of Texas Human Factors Research ProjectHuman Factors Research Project

www.psy.utexas.edu/HumanFactors