Safety in the nonoperating room anesthesia suite is not an accident: lessons from the National Transportation Safety Board.

PURPOSE OF REVIEW: To review the findings of National Transportation Safety Board-related aviation near misses and catastrophes and apply these principles to the nonoperating room anesthesia (NORA) suite. RECENT FINDINGS: NORA is a specialty that has seen tremendous growth. In 2019, NORA contributes to a larger proportion of anesthesia practice than ever before. With this growth, the NORA anesthesiologist and team are challenged to provide safe, high-quality care for more patients, often with complex comorbidities, and are forced to utilize deeper levels of sedation and anesthesia than ever before. These added pressures create new avenues for human error and adverse outcomes. SUMMARY: Safety in modern anesthesia practice often draws comparison to the aviation industry. From distinct preoperational checklists, defined courses of action, safety monitoring and the process of guiding individuals through a journey, there are many similarities between the practice of anesthesia and flying an airplane. Consistent human performance is paramount to creating safe outcomes. Although human errors are inevitable in any complex process, the goal for both the pilot and physician is to ensure the safety of their passengers and patients, respectively. As the aviation industry has had proven success at managing human error with a dramatic improvement in safety, a deeper look at several key examples will allow for comparisons of how to implement these strategies to improve NORA safety.

What went right? An analysis of the protective factors in aviation near misses.

Learning from successful safety outcomes, or what went right, is an important emerging component of maintaining safe systems. Accordingly, there are increasing calls to study normal performance in near misses as a part of safety management activities. Despite this, there is limited guidance on how to accomplish this in practice. This article presents a study in which using Rasmussen's risk management framework to analyse 16 serious incidents from the aviation domain. The findings show that a network of protective factors prevents accidents with factors identified across the sociotechnical system. These protective networks share many properties with those identified in accidents. The article demonstrates that is possible to identify these networks of protective factors from incident investigation reports. The theoretical implications of these results and future research opportunities are discussed. Practitioner Statement: The analysis of near misses is an important part of safety management activities. This article demonstrates that Rasmussen?s risk management framework can be used to identify networks of protective factors which prevent accidents. Safety practitioners can use the framework described to discover and support the system-wide networks of protective factors.

Parallels in safety between aviation and healthcare.

Aviation and healthcare are complex industries and share many similarities: the cockpit and the operating theater, the captain and the surgeon. While North American commercial aviation currently enjoys a tremendous safety record, it was not always this way. A spike of accidents in 1973 caused 3214 aviation-related fatalities. Over the past 20years, the rate of fatal accidents per million flights fell by a factor of five, while air traffic increased by more than 86%. There have been no fatalities on a U.S. carrier for over 12years. Last year, there were 251,454 deaths in the United States owing to medical error. Pilots pioneered ways to address risks through crew resource management (CRM), and threat and error management (TEM). Both strategies, which are aimed at minimizing risk and optimizing safety, are applicable to surgery and the healthcare industry. These strategies as well as the Swiss Cheese Model, Checklists and the Normalization of Deviance will be reviewed in this article.

A sonic net excludes birds from an airfield: implications for reducing bird strike and crop losses.

Collisions between birds and aircraft cause billions of dollars of damages annually to civil, commercial, and military aviation. Yet technology to reduce bird strike is not generally effective, especially over longer time periods. Previous information from our lab indicated that filling an area with acoustic noise, which masks important communication channels for birds, can displace European Starlings (Sturnus vulgaris) from food sources. Here we deployed a spatially controlled noise (termed a "sonic net"), designed to overlap with the frequency range of bird vocalizations, at an airfield. By conducting point counts, we monitored the presence of birds for four weeks before deployment of our sonic net, and for four weeks during deployment. We found an 82% reduction in bird presence in the sonic net area compared with change in the reference areas. This effect was as strong in the fourth week of exposure as in the first week. We also calculated the potential costs avoided resulting from this exclusion. We propose that spatially controlled acoustic manipulations that mask auditory communication for birds may be an effective long term and fairly benign way of excluding problem birds from areas of socioeconomic importance, such as airfields, agricultural sites, and commercial properties.

Surgeons' attitudes are associated with reoperation and readmission rates.

BACKGROUND: Attitudes influence how people make decisions. In an effort to decrease pilot judgment-related accidents, the Federal Aviation Administration teaches new pilots about hazardous attitudes that are believed to be incompatible with safe flight: macho, impulsive, worry, resignation, self-confidence, and antiauthority. If these attitudes are hazardous for pilots and their passengers, they may also be incompatible with the reliable and safe delivery of surgical care. QUESTIONS/PURPOSES: The purposes of this study were (1) to ascertain to what extent surgeons harbor hazardous attitudes; and (2) to determine their relationship, if any, to reoperation and readmission rates. METHODS: We selected validated aviation psychology tools that are used to measure these attitudes in pilots. We converted the aviation scenarios to analogous situations for surgeons and invited all surgeons from one academic program to participate in this study. A total of 41 surgeons were eligible to participate; 37 (90%) completed the attitude prevalence protocol and 31 (76%) had complete reoperation and readmission data for the correlation and regression analysis. Attending orthopaedic surgeons completed the Modified Surgeon Hazardous Attitude Scale as well as a series of additional instruments. RESULTS: Levels of macho thought to be hazardous in pilots were present in nine (24%) surgeons. Similar, elevated levels of self-confidence were found in three (8%) surgeons. High levels of impulsivity were found in 5% (two surgeons) and high levels of antiauthority were found in 3% (one surgeon). Only one (3%) surgeon reported elevated levels of worry and no surgeon reported hazardous levels of resignation. Thirty percent (11 surgeons) of surgeons harbored at least one elevated attitude level. In a regression model, macho attitude levels predicted 19% of the variation in surgeons' rate of readmissions and reoperations. CONCLUSIONS: High levels of hazardous attitudes may not be consistent with the routine delivery of safe surgical care in a teamwork setting where human factors and safe systems are the key to success. Further research is needed to determine if abnormally high levels of these hazardous attitudes impact patient care. LEVEL OF EVIDENCE: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

[Learning from errors: applying aviation safety concepts to medicine]. / Aus Fehlern lernen : Sicherheitskonzepte der Luftfahrt in der Medizin anwenden.

Health care safety levels range below other complex industries. Civil aviation has throughout its history developed methods and concepts that have made the airplane into one of the safest means of mass transport. Key elements are accident investigations that focus on cause instead of blame, human-centered design of machinery and processes, continuous training of all personnel and a shared safety culture. These methods and concepts can basically be applied to medicine which has successfully been achieved in certain areas, however, a comprehensive implementation remains to be completed. This applies particularly to including the topic of safety into relevant curricula. Physicians are obliged by the oath"primum nil nocere" to act, but economic as well as political pressure will eventually confine professional freedom if initiative is not taken soon.

[ORION®: a simple and effective method for systemic analysis of clinical events and precursors occurring in hospital practice]. / Méthode Orion(®) : analyse systémique simple et efficace des événements cliniques et des précurseurs survenant en pratique médicale hospitalière.

PURPOSE: Morbimortality review is now recommended by the French Health Authority (Haute Autorité de santé [HAS]) in all hospital settings. It could be completed by Comités de retour d'expérience (CREX), making systemic analysis of event precursors which may potentially result in medical damage. As commonly captured by their current practice, medical teams may not favour systemic analysis of events occurring in their setting. They require an easy-to-use method, more or less intuitive and easy-to-learn. It is the reason why ORION(®) has been set up. METHODS: ORION(®) is based on experience acquired in aeronautics which is the main precursor in risk management since aircraft crashes are considered as unacceptable even though the mortality from aircraft crashes is extremely low compared to the mortality from medical errors in hospital settings. The systemic analysis is divided in six steps: (i) collecting data, (ii) rebuilding the chronology of facts, (iii) identifying the gaps, (iv) identifying contributing and influential factors, (v) proposing actions to put in place, (vi) writing the analysis report. When identifying contributing and influential factors, four kinds of factors favouring the event are considered: technical domain, working environment, organisation and procedures, human factors. Although they are essentials, human factors are not always considered correctly. The systemic analysis is done by a pilot, chosen among people trained to use the method, querying information from all categories of people acting in the setting. RESULTS: ORION(®) is now used in more than 400 French hospital settings for systemic analysis of either morbimortality cases or event precursors. It is used, in particular, in 145 radiotherapy centres for supporting CREX. CONCLUSION: As very simple to use and quasi-intuitive, ORION(®) is an asset to reach the objectives defined by HAS: to set up effective morbi-mortality reviews (RMM) and CREX for improving the quality of care in hospital settings. By helping the efforts of medical teams, ORION(®) is an essential tool contributing to the patients' security.

An NTSB for health care: learning from innovation: debate and innovate or capitulate.

INTRODUCTION: Economic and medical risks threaten the national security of America. The spiraling costs of United States' avoidable healthcare harm and waste far exceed those of any other nation. This 2-part paper, written by a group of aviators, is a national call to action to adopt readily available and transferable safety innovations we have already paid for that have made the airline industry one of the safest in the world. This first part supports the debate for a National Transportation Safety Board (NTSB) for health care, and the second supports more cross-over adoption by hospitals of methods pioneered in aviation. METHODS: A review of aviation and healthcare leadership best practices and technologies was undertaken through literature review, reporting body research, and interviews of experts in the field of aviation principles applied to medicine. An aviation cross-over inventory and consensus process led to a call for action to address the current crisis of healthcare waste and harm. RESULTS: The NTSB, an independent agency established by the United States Congress, was developed to investigate all significant transportation accidents to prevent recurrence. Certain NTSB publications known as "Blue Cover Reports" used by pilots and airlines to drive safety provide a model that could be emulated for hospital accidents. CONCLUSION: An NTSB-type organization for health care could greatly improve healthcare safety at low cost and great benefit. A "Red Cover Report" for health care could save lives, save money, and bring value to communities. A call to action is made in this first paper to debate this opportunity for an NTSB for health care. A second follow-on paper is a call to action of healthcare suppliers, providers, and purchasers to reinvigorate their adoption of aviation best practices as the market transitions from a fragmented provider-volume-centered to an integrated patient-value-centered world.

Reducing health care hazards: lessons from the commercial aviation safety team.

The movement to improve quality of care and patient safety has grown, but examples of measurable and sustained progress are rare. The slow progress made in health care contrasts with the success of aviation safety. After a tragic 1995 plane crash, the aviation industry and government created the Commercial Aviation Safety Team to reduce fatal accidents. This public-private partnership of safety officials and technical experts is responsible for the decreased average rate of fatal aviation accidents. We propose a similar partnership in the health care community to coordinate national efforts and move patient safety and quality forward.

Comparative issues in aviation and surgical crew resource management: (1) are we too solution focused?

Although the published work in health care increasingly promotes aviation as a high-reliability industry to be emulated, there is little empirical research to justify equating the dynamics of health care's operating environment with that of aviation. This article examines some of the potential key areas of difference between the two professional groups with respect to crew resource management. The risks of implementing crew resource management training in health care without an evidential basis are discussed.