European Association of Oral Medicine 2021 Conference - Crispian Scully Lecture: Applying Human Factors to Improve Patient Safety and Performance.

BACKGROUND: This paper is a synopsis of the Crispian Scully Lecture, presented by one of the authors (PAB), at the 2021 European Association of Oral Medicine (EAOM) Conference in Lisbon, Portugal. It provides an overview of human factors that affect individuals and teams, highlighting ways to reduce the chances of error and improve patient safety. DISCUSSION AND CONCLUSION: Error is an inevitable and 'normal' part of being human, and it can never be completely eliminated, though learning from mistakes is essential. Human factor application in health care can greatly improve patient safety and lead to better team working and staff morale. Personal factors including tiredness, hunger, dehydration and stress can all reduce performance and raise the risk of clinical error. It is also important to understand and optimise interaction within the clinical team. Poor communication, steep hierarchy and loss of situational awareness can all potentially compromise patient safety.

Airway pressure release ventilation improves pulmonary blood flow in infants after cardiac surgery.

OBJECTIVE: We hypothesized that spontaneous inspiratory effort transmitted to the pleural space during airway pressure release ventilation would result in increased lung perfusion after surgery for tetralogy of Fallot or following a cavopulmonary shunt as a consequence of transient decreases in intrapleural pressure. DESIGN: Prospective crossover cohort study. SETTING: A tertiary care cardiac pediatric intensive care unit. PATIENTS: Children after tetralogy of Fallot repair, cavopulmonary shunt, or Fontan operation. INTERVENTIONS: Lung perfusion and cardiac output were measured during airway pressure release ventilation and pressure control ventilation with pressure support, both with and without spontaneous ventilation. Oxygen consumption was measured (mass spectrometer) and lung perfusion/cardiac output calculated (Fick equation). Constant levels of CO2 and mean airway pressure were targeted in all study phases. MEASUREMENTS AND MAIN RESULTS: Twenty patients were enrolled in the study, nine after repair of tetralogy of Fallot and 11 after a cavopulmonary shunt. In the absence of spontaneous ventilation, there were no differences in lung perfusion or any of the measured gas exchange or hemodynamic parameters. In the presence of spontaneous ventilation for all patients, mean pulmonary blood flow increased from 2.4 to 2.9 L·min⁻¹M⁻² (p = .02). Oxygen delivery increased from 594 to 774 mL/min/m² (p = .05) in the patients with tetralogy of Fallot patients and from 473 to 518 L·min⁻¹M⁻² (p = .07) in the cavopulmonary shunt group. CONCLUSION: Ventilation with airway pressure release ventilation (at comparable mean airway pressure) improves lung perfusion compared with pressure control ventilation in children after tetralogy of Fallot repair and cavopulmonary shunt operations. Although this study focused on tetralogy of Fallot and cavopulmonary shunt operations, the improved cardiopulmonary interactions may be beneficial in other situations in which hemodynamics are impaired by positive pressure ventilation.

Instructor perceptions of the accident likelihood faced by recently trained glider pilots.

INTRODUCTION: U.K. glider pilots with less than 10 h of solo flying time have been shown to have the highest accident rate and be most vulnerable to accidents during the 'final approach' phase. METHOD: There were 58 gliding instructors who were asked to indicate what experience level they thought was associated with the highest accident rate and provide the reason behind their estimate. They were also asked to rank six flight phases by the relative probability of accidents to inexperienced pilots. RESULTS: The mean estimate for the accident peak was 296.3 h as pilot-in-command (SD = 337.9) with no instructor giving a figure of less than 10 h. Common reasons for these estimates were 'over-confidence', 'risk-taking', or 'complacency'. Instructors also ranked six flight phases by the likelihood of an accident being caused by inexperienced pilots during that phase. Despite the approach phase having the highest objective accident probability, it was only ranked fifth by instructors, indicating an underestimate of the danger it presents to newly trained pilots. DISCUSSION: The results suggest that instructors do not appreciate the high accident likelihood of early solo pilots or the main dangers they face. This has implications for the decisions made when sending pilots solo.

Development of a bespoke human factors taxonomy for gliding accident analysis and its revelations about highly inexperienced UK glider pilots.

Low-hours solo glider pilots have a high risk of accidents compared to more experienced pilots. Numerous taxonomies for causal accident analysis have been produced for powered aviation but none of these is suitable for gliding, so a new taxonomy was required. A human factors taxonomy specifically for glider operations was developed and used to analyse all UK gliding accidents from 2002 to 2006 for their overall causes as well as factors specific to low hours pilots. Fifty-nine categories of pilot-related accident causation emerged, which were formed into progressively larger categories until four overall human factors groups were arrived at: 'judgement'; 'handling'; 'strategy'; 'attention'. 'Handling' accounted for a significantly higher proportion of injuries than other categories. Inexperienced pilots had considerably more accidents in all categories except 'strategy'. Approach control (path judgement, airbrake and speed handling) as well as landing flare misjudgement were chiefly responsible for the high accident rate in early solo glider pilots. Statement of Relevance: This paper uses extant accident data to produce a taxonomy of underlying human factors causes to analyse gliding accidents and identify the specific causes associated with low hours pilots. From this specific, well-targeted remedial measures can be identified.

Looking for an accident: glider pilots' visual management and potentially dangerous final turns.

INTRODUCTION: Accidents caused by spinning from low turns continue to kill glider pilots despite the introduction of specific exercises aimed at increasing pilot awareness and recognition of this issue. METHOD: In-cockpit video cameras were used to analyze flying accuracy and log the areas of visual interest of 36 qualified glider pilots performing final turns in a training glider. RESULTS: Pilots were found to divide their attention between four areas of interest: the view directly ahead; the landing area (right); the airspeed indicator; and an area between the direct ahead view and the landing area. The mean fixation rate was 85 shifts per minute. Significant correlations were found between over-use of rudder and a lack of attention to the view ahead, as well as between the overall fixation rate and poorer coordination in the turn. DISCUSSION: The results provide some evidence that a relationship exists between pilots' visual management and making turns in a potentially dangerous manner. Pilots who monitor the view ahead for reasonable periods during the final turn while not allowing their scan to become over-busy are those who are most likely to prevent a potential spin.

Accident rates for novice glider pilots vs. pilots with experience.

INTRODUCTION: It is a popular notion in gliding that newly soloed pilots have a low accident rate. The intention of this study was to review the support for such a hypothesis from literature and to explore it using UK accident totals and measures of flying exposure. METHOD: Log sheets from UK gliding clubs were used to estimate flying exposure for inexperienced glider pilots. This was used along with accident data and annual flight statistics for the period 2004-2006 in order to estimate accident rates that could be compared between the pilot groups. RESULTS: The UK accident rate for glider pilots from 2004-2006 was 1 accident in every 3534 launches and 1590 flying hours. The lowest estimated rate for pilots with up to 1 h of experience was 1 accident every 976 launches and 149 h flown. For pilots with up to 10 h of experience the figures were 1 accident in 1274 launches and 503 h. DISCUSSION: From 2004-2006 UK glider pilots with 10 h or less experience in command had twice the number of accidents per launch and three times as many accidents per hour flown than average for UK glider pilots. Pilots with only 1 h of experience or less were involved in at least 10 times the number of accidents per hour flown than the UK average and had more than 3.5 times the number of accidents per launch.

Nighttime approaches to offshore installations in Brazil: Safety shortcomings experienced by helicopter pilots.

Accident rates for night sorties by helicopters traveling to offshore oil and gas platforms are at least five times higher than those during the daytime. Because pilots need to transition from automated flight to a manually flown night visual segment during arrival, the approach and landing phases cause great concern. Despite this, in Brazil, regulatory changes have been sought to allow for the execution of offshore night flights because of the rapid expansion of the petroleum industry. This study explores the factors that affect safety during night visual segments in Brazil using 28 semi-structured interviews with offshore helicopter pilots, followed by a template analysis of the narratives. The relationships among the factors suggest that flawed safety oversights, caused by a combination of lack of infrastructure for night flights offshore and declining training, currently favor spatial disorientation on the approach and near misses when close to the destination. Safety initiatives can be derived on the basis of these results.

Serious gaming technology in major incident triage training: a pragmatic controlled trial.

OBJECTIVE: By exploiting video games technology, serious games strive to deliver affordable, accessible and usable interactive virtual worlds, supporting applications in training, education, marketing and design. The aim of the present study was to evaluate the effectiveness of such a serious game in the teaching of major incident triage by comparing it with traditional training methods. DESIGN: Pragmatic controlled trial. METHOD: During Major Incident Medical Management and Support Courses, 91 learners were randomly distributed into one of two training groups: 44 participants practiced triage sieve protocol using a card-sort exercise, whilst the remaining 47 participants used a serious game. Following the training sessions, each participant undertook an evaluation exercise, whereby they were required to triage eight casualties in a simulated live exercise. Performance was assessed in terms of tagging accuracy (assigning the correct triage tag to the casualty), step accuracy (following correct procedure) and time taken to triage all casualties. Additionally, the usability of both the card-sort exercise and video game were measured using a questionnaire. RESULTS: Tagging accuracy by participants who underwent the serious game training was significantly higher than those who undertook the card-sort exercise [Chi2=13.126, p=0.02]. Step accuracy was also higher in the serious game group but only for the numbers of participants that followed correct procedure when triaging all eight casualties [Chi2=5.45, p=0.0196]. There was no significant difference in time to triage all casualties (card-sort=435+/-74 s vs video game=456+/-62 s, p=0.155). CONCLUSION: Serious game technologies offer the potential to enhance learning and improve subsequent performance when compared to traditional educational methods.

Development of a bespoke human factors taxonomy for gliding accident analysis and its revelations about highly inexperienced UK glider pilots.

Low-hours solo glider pilots have a high risk of accidents compared to more experienced pilots. Numerous taxonomies for causal accident analysis have been produced for powered aviation but none of these is suitable for gliding, so a new taxonomy was required. A human factors taxonomy specifically for glider operations was developed and used to analyse all UK gliding accidents from 2002 to 2006 for their overall causes as well as factors specific to low hours pilots. Fifty-nine categories of pilot-related accident causation emerged, which were formed into progressively larger categories until four overall human factors groups were arrived at: 'judgement'; 'handling'; 'strategy'; 'attention'. 'Handling' accounted for a significantly higher proportion of injuries than other categories. Inexperienced pilots had considerably more accidents in all categories except 'strategy'. Approach control (path judgement, airbrake and speed handling) as well as landing flare misjudgement were chiefly responsible for the high accident rate in early solo glider pilots.

Optimizing nutrient management for farm systems.

Increasing the inputs of nutrients has played a major role in increasing the supply of food to a continually growing world population. However, focusing attention on the most important nutrients, such as nitrogen (N), has in some cases led to nutrient imbalances, some excess applications especially of N, inefficient use and large losses to the environment with impacts on air and water quality, biodiversity and human health. In contrast, food exports from the developing to the developed world are depleting soils of nutrients in some countries. Better management of all essential nutrients is required that delivers sustainable agriculture and maintains the necessary increases in food production while minimizing waste, economic loss and environmental impacts. More extensive production systems typified by 'organic farming' may prove to be sustainable. However, for most of the developed world, and in the developing world where an ever-growing population demands more food, it will be essential to increase the efficiency of nutrient use in conventional systems. Nutrient management on farms is under the control of the land manger, the most effective of whom will already use various decision supports for calculating rates of application to achieve various production targets. Increasingly, land managers will need to conform to good practice to achieve production targets and to conform to environmental targets as well.

Use of labelled nitrogen to measure gross and net rates of mineralization and microbial activity in permanent pastures following fertilizer applications at different time intervals.

Measurements of some of the main internal N-cycling processes in soil were obtained by labelling the inorganic N pool with the stable isotope of nitrogen ((15)N). The (15)N mean pool dilution technique, combined with other field measurements, enabled gross and net N-mineralization rates to be resolved in grassland soils, which had previously either received fertilizer N (F), or had remained unfertilized (U) for many years. The two soils were subdivided into plots that received N at different time intervals (over 3 weeks), prior to (15)N measurements being made. By this novel approach, possible 'priming' effects over time were investigated to try to overcome some of the temporal problems of isotopic labelling of soil N (native plus fertilizer) and to identify possible changes in a range of primary N-transformation processes. The results suggested that an overall stimulation of microbially mediated processes occurred with all N treatments, but there were inconsistencies associated with the release of N, both in the timing and the degree to which different processes responded to the application of fertilizer N. The rates of these processes were, however, within the range of previously reported data and the (15)N measurements were not adversely affected by the differences in N pools created by the treatments. Thus, the mean pool dilution technique was shown to be applicable to agricultural soils, under conditions relevant to grass swards receiving fertilizer. For example, between the U and F treatments, the size of inorganic N pools increased by five-fold and gross rates of mineralization reached 3.5 and 4.8 microg N g(-1) (dry soil) d(-1), respectively, but did not vary greatly with the timing of N applications. A correlation (r(2) = 0.57) was found between soil respiration (which is relatively simple to measure) and net mineralization (which is more time consuming), suggesting that the former might be used as an indicator of the latter. Although this relationship was stronger in previously unfertilized soils, the similarities found with fertilized soils suggest that this approach could be used to obtain information of wider agronomic value and would, therefore, warrant further work under a range of soil conditions.