Threat and Error in Threat and Error in Medicine:Medicine:

Lessons from AviationLessons from Aviation

Robert Helmreich, Ph.D.Robert Helmreich, Ph.D.University of Texas University of Texas

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

Methodist Healthcare SystemMethodist Healthcare SystemSan AntonioSan Antonio

September 12, 2002September 12, 2002

Research into:Research into: Personality and performancePersonality and performance Team and crew behaviourTeam and crew behaviour Living in isolation and confinementLiving in isolation and confinement Organizational and professional culturesOrganizational and professional cultures

UT Human Factors Research UT Human Factors Research ProjectProject

UT Human Factors Research UT Human Factors Research ProjectProject

Funding agencies:Funding agencies: NASANASA FAAFAA NSBRINSBRI Daimler BenzDaimler Benz AHRQAHRQ

Human error Human error in aviationin aviation

LOSALOSA In-fight In-fight

ObservationObservation ASAPASAP

Confidential Confidential reporting systemreporting system

SelectionSelection Personality trait Personality trait

assessmentassessment

Space Space and and AstronauticsAstronautics

Astronaut Astronaut Performance and Performance and SelectionSelection Personality trait Personality trait

assessmentassessment

Antarctic Antarctic Research StationsResearch Stations- - multi center collaborationmulti center collaboration

Personality Personality selection, & selection, & performanceperformance

Small group Small group behavior behavior

Medical Error and culture in Medical Error and culture in medicinemedicine

AHRQ Center of AHRQ Center of Excellence in patient Excellence in patient Safety (UT System)Safety (UT System) Incident reportingIncident reporting Professional cultureProfessional culture Organizational cultureOrganizational culture Team behaviorTeam behavior

Human error in the Human error in the NICU (with UT Houston)NICU (with UT Houston)

The Institute of Medicine Report The Institute of Medicine Report ‘‘To Error is Human’ recommended To Error is Human’ recommended

adapting aviation’s approaches to adapting aviation’s approaches to safety and error managementsafety and error management

The University of Texas research group The University of Texas research group is active in both aviation and medicineis active in both aviation and medicine

Why look for answers from Why look for answers from aviation?aviation?

The operating room is not a cockpitThe operating room is not a cockpit

Medicine is much more complexMedicine is much more complex

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 Second guessing after disasterdisaster– Air crashesAir crashes

– Sentinel eventsSentinel events

Teamwork is essentialTeamwork is essential

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

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

Nor does even newer technologyNor does even newer technology

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

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, 3 Cultures – National, Organizational, ProfessionalOrganizational, Professional

Culture influences how juniors relate to their Culture influences how juniors relate to their seniorsseniors

Culture influences how information is sharedCulture influences how information is shared Culture influences attitudes regarding stress Culture influences attitudes regarding stress

and personal capabilitiesand 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 physicians have a strong Pilots and physicians have a strong professional cultures with both positive professional cultures with both positive and negative aspectsand negative aspects

Positive:Positive:– Strong motivation Strong motivation

to do wellto do well– Pride in professionPride in profession

Negative:Negative:– Training that stresses Training that stresses

the need for the need for perfectionperfection

– Sense of personal Sense of personal invulnerabilityinvulnerability

Professional culture in Professional culture in AviationAviation

Maintaining high individual standardsMaintaining high individual standards Continual performance evaluationContinual performance evaluation Pushing the limits of performance – Pushing the limits of performance –

“press-on”“press-on” Invulnerability to fatigue and other Invulnerability to fatigue and other

frailtiesfrailties Individual vs. team performanceIndividual vs. team performance

Some resistance to standardizationSome resistance to standardization

Professional culture in Professional culture in medicinemedicine

Intolerance of error in both self and othersIntolerance of error in both self and others Long work hours – beginning in trainingLong work hours – beginning in training Adversarial relationship with the legal worldAdversarial relationship with the legal world A dearth of competency assessment following A dearth of competency assessment following

trainingtraining Maintenance of high standards through Maintenance of high standards through

punitive boards and litigation fearspunitive boards and litigation fears Characteristic differences between specialtiesCharacteristic differences between specialties Individual freedom in practice styleIndividual freedom in practice style Resistance to organization and administrationResistance to organization and administration

““Trying to herd cats”Trying to herd cats”

ThreatThreat

Threats in Medicine

OrganizationalOrganizational CultureScheduling & Staffing

Experience levelsWork LoadError policy

Equipment issues

System - levelNational culture

Health-care policyand regulation

Payment modalitiesMedical coverage

ProfessionalProficiency

FatigueMotivation

Culture(Invulnerability)

Patient**Primary illness

Secondary illnessRisk Factors

Atypical responseto treatment

Ongoing management

Expected Events and RisksUnexpected Events and Risks

** Well known and expected

Professional culture as a Professional culture as a latent threatlatent threat

Supressing discussion of medical errorsSupressing discussion of medical errors Tolerance of detrimental behaviorsTolerance of detrimental behaviors

Handwriting, nurse-physician conflictHandwriting, nurse-physician conflict

Variability of practice standardsVariability of practice standards Individual variation in medical Individual variation in medical

proceduresprocedures Lack of familiarity to supporting personnelLack of familiarity to supporting personnel Clinical practice standardsClinical practice standards

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

%

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

Fatigue in AviationFatigue in Aviation

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 hours in one month, 1,000 hours per yearper year

Reserve crew members for Reserve crew members for extended flightsextended flights

Fatigue is still considered a Fatigue is still considered a significant problemsignificant problem

New Rules from ACGMENew Rules from ACGME Accreditation Counsel for Graduate Accreditation Counsel for Graduate

Medical Education 7/2003Medical Education 7/2003 24 hours in 1 shift (+6)24 hours in 1 shift (+6) 80 hours in 1 week (+8) (4 week 80 hours in 1 week (+8) (4 week

average)average) No limit for month or yearNo limit for month or year

What Effect Will ACGME Have?What Effect Will ACGME Have?

Non-compliance?Non-compliance? Libby Zion case in NYLibby Zion case in NY

Health costs?Health costs? Lawyers’ picnic?Lawyers’ picnic? Reduction in error?Reduction in error?

ErrorError

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

Reluctance to discuss errorReluctance to discuss error Due to Due to

Fear of litigationFear of litigation Reactions from peersReactions from peers Action by state boards and peer review Action by state boards and peer review

committeescommittees Fear of impact on practice and referralsFear of impact on practice and referrals Loss of status and self esteemLoss of status and self esteem

Implications of hiding medical Implications of hiding medical errorerror

Increased likelihood of litigationIncreased likelihood of litigation Failure to improve the system Failure to improve the system

through lessons learnedthrough lessons learned Increased psychological burden on Increased psychological burden on

practitionerspractitioners Negative impact on practice styleNegative impact on practice style

Attempts to change Attempts to change professional culture and professional culture and

behaviorbehavior

Aviation and MedicineAviation and Medicine Some similarities, some differencesSome similarities, some differences

Changing the culture in Changing the culture in AviationAviation

Human limitation awarenessHuman limitation awareness CRM TrainingCRM Training

Fatigue limitationsFatigue limitations Strictly enforced, FAA mandated duty time limitationsStrictly enforced, FAA mandated duty time limitations

Failures of teamworkFailures of teamwork CRM training focused on crew coordinationCRM training focused on crew coordination

Skills maintenanceSkills maintenance Ongoing training, simulation, FAA and Carrier mandated Ongoing training, simulation, FAA and Carrier mandated

proficiency checksproficiency checks Simplify complex, error prone systemsSimplify complex, error prone systems

Automation, checklists, standardizationAutomation, checklists, standardization

What have been key factors in What have been key factors in changing pilot changing pilot

culture/behaviour?culture/behaviour?

Strong organizational leadershipStrong organizational leadership Data to identify threats and support Data to identify threats and support

interventionsinterventions Some degree of regulationSome degree of regulation Public pressure through high visibility of Public pressure through high visibility of

air disasters and magnitude of resulting air disasters and magnitude of resulting legal actionslegal actions

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

Optimize Input FactorsOptimize Input Factors

IndividualIndividual– Qualification and recurrent qualificationQualification and recurrent qualification– Training in human factorsTraining in human factors

OrganizationalOrganizational– Culture and communicationCulture and communication– ProceduresProcedures– Policies toward errorPolicies toward error– Collect meaningful dataCollect meaningful data

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-proceduralizedAviation is arguably over-proceduralized– 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 generations CRM training has evolved through 6 generations

from psychobabble management training to from psychobabble management training to

threat and error management integrated with threat 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 medicine maritime domains – and medicine

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

A focus of CRM is sharing A focus of CRM is sharing one’s one’s

mental model - common mental model - common understandingunderstandingof the situationof the situation

What Can an Organization Do?What Can an Organization Do?

Define a clear policy regarding human Define a clear policy regarding human errorerror

Proceduralize where appropriateProceduralize where appropriate Recognize the dangers in fatigueRecognize the dangers in fatigue Use protected confidential reporting Use protected confidential reporting

systems to uncover threatssystems to uncover threats Provide formal training in threat and error Provide formal training in threat and error

managementmanagement

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

www.psy.utexas.edu/www.psy.utexas.edu/HumanFactorsHumanFactors