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Culture, Threat, and Error: Lessons from Aviation

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Title: Culture, Threat, and Error: Lessons from Aviation


1
Culture, Threat, and Error Lessons from Aviation
  • Robert L. Helmreich, Ph.D.
  • The University of Texas
  • Human Factors Research Project
  • Israeli Medical Association
  • Jerusalem
  • February 25, 2005

2
  • The U.S. Institute of Medicine Report
  • To Err is Human recommended that medicine adopt
    aviations approaches
  • to safety and error management

3
Medicine and Aviation
  • Safety is primary goal
  • But cost drives decisions
  • Technological innovation
  • Multiple sources of threat
  • Second guessing after disaster
  • Air crashes
  • Sentinel events
  • Teamwork is essential

4
Why Teamwork Matters
  • Most endeavours in medicine, science, and
    industry require groups to work together
    effectively -- teamwork
  • Failures of teamwork in complex organizations can
    have deadly effects
  • More than 2/3 of air crashes involve human error,
    especially failures in teamwork
  • Professional training has focused on technical,
    not interpersonal, skills

5
Team Performance Factors
  • Individual knowledge and skill
  • Organizational characteristics
  • Team composition
  • Culture

6
The Importance of Culture
  • Culture is the values, beliefs, and behaviors
    that we share with other members of groups
  • Culture binds us together as a group
  • Culture provides cues and clues on how to behave
    in normal and novel situations
  • Culture is implicated in accidents and incidents
    in aviation and medicine

7
Intersecting Cultures
  • Professional culture
  • Norms, attitudes, values and practices associated
    with being a pilot or doctor or nurse
  • Organizational culture
  • The norms, attitudes, values, and practices of an
    airline or hospital

8
Cultures Consequences
  • Culture influences how juniors relate to their
    seniors
  • Unwillingness to speak up vs. assertive
  • Culture influences how information is shared
  • Use of direct versus indirect speech
  • Culture influences attitudes regarding stress and
    personal capabilities
  • Culture influences adherence to rules
  • Culture influences interaction with computers and
    technology

9
Organizational Culture
  • An organizations culture reflects
  • Values regarding error, blame, and punishment
  • Openness of communications between management and
    pilots
  • Level of adherence to regulations
  • Level of commitment to safety
  • Level of trust between pilots and management

10
Flawed Organizational Culture and Air Crashes
  • Lack of safety concerns
  • Operational pressures
  • Poor leadership
  • Conflict with management
  • Low morale

11
Professional Culture
  • Pilots and doctors have a strong professional
    culture with positive and negative aspects
  • Positive
  • Strong motivation to do well
  • Pride in profession
  • Negative
  • Training that stresses the need for perfection
  • Sense of personal invulnerability

12
Personal Invulnerability
  • The majority of pilots and doctors in all
    cultures agree that
  • their decision-making is as good in emergencies
    as in normal situations
  • their performance is not affected by personal
    problems
  • they do not make more errors under high stress
  • true professionals can leave behind personal
    problems

13
Pilots and Doctors Attitudes
Decision making as good in emergencies as
normal Effective pilot/doctor can leave behind
personal problems Performance the same with
inexperienced team Perform effectively
when fatigued

14
Other Safety Issues in Medicine
  • Suppressing discussion of medical errors
  • Tolerance of detrimental behaviors
  • Handwriting, nurse-physician conflict
  • Variability of practice standards
  • Individual variation in medical procedures

15
Threats to Safety in Medicine
  • Events or errors that occur outside the influence
    of the crew, increase operational complexity, and
    must be managed to maintain the margin of safety

16
The Many Sources of Threat
Organizational Level Organizational
Culture Scheduling Staffing Experience
levels Work Load Error policy Equipment issues
System Level National culture Health-care
policy and regulation Payment modalities Medical
coverage
Professional Level Proficiency Fatigue Motivation
Culture (Invulnerability)
Patient Level Primary illness Secondary
illness Risk Factors Atypical response to
treatment Ongoing management
17
Fatigue as Threat
  • 24 hours of sleep deprivation have performance
    effects comparable to a blood alcohol content of
    0.1 Drew Dawson Nature, 1997
  • Aviation flight time limits
  • 8 hours in one day, 30 hours in one week, 100
    hours in one month, 1,000 hours per year
  • U.S. Resident workrules (July 2003)
  • 24 hours in one shift (6)
  • 80 hours in one week (8 4 week average)
  • No limit for month or year

18
Fatigue Contributed
19
Error
  • Action or inaction that leads to a deviation from
    crew or organizational intentions or expectations

20
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21
44.000-98.000 deaths/year dues to medical error -
IOM Report
Deaths Due to Medical Errors Are Exaggerated in
Institute of Medicine Report -McDonald et. Al.,
JAMA 5 Jul 2000 Institute of Medicine Medical
Error Figures Are Not Exaggerated - Leape, JAMA
5 Jul 2000
22
Error is Inevitable Because of Human Limitations
  • Limited memory capacity
  • Limited mental processing capacity
  • Negative effects of stress
  • Tunnel vision
  • Negative influence of fatigue and other
    physiological factors

23
  • Dealing with technology is a source of threat and
    error

24
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25
Newer technology doesnt eliminate error
26
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27
Nor does even newer technology
28
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29
Problems at the Interface Between Teams
  • We have observed many instances of conflict
    between surgical and anesthesia teams

30
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31
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32
Typology of Observable Team Error
  • 1. Task Execution Unintentional physical act
    that deviates from intended course of action
  • 2. Procedural Unintentional failure to follow
    mandated procedures
  • 3. Communication Failure to transmit
    information, failure to understand information,
    failure to share mental model
  • 4. Decision Choice of action unbounded by
    procedures that unnecessarily increase risk
  • 5. Intentional Noncompliance Violations of
    formal procedures or regulations

33
The University of Texas Threat and Error
Management Model (TEMM)
  • Template for analysis of superior and flawed
    performance
  • Conceptual framework for formal training in
    threat and error management
  • Used in analysis of air crashes, adverse events
    and close calls

34
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35
Antidotes to Threat and Error
36
Building a Safety Culture What Organizations
Can Do
  • Define a clear policy regarding human error
  • Accept error but not intentional non-compliance
  • Recognize the dangers in fatigue
  • Use confidential reporting systems to uncover
    threats and sources of error
  • Analyze near miss/adverse/sentinel events using
    Threat and Error Management concept
  • Institute formal procedures where appropriate
  • Provide formal training in Threat and Error
    Management

37
Procedures
  • Standard Operating Procedures (SOPs) were
    aviations first countermeasures against threat
    and error
  • Aviation is arguably over-proceduralized
  • Tombstone regulation
  • Medicine is under-proceduralized
  • Example Checklists are critical error
    countermeasures in aviation
  • Less widely used in Medicine

38
Training Topics in Threat and Error Management
  • Human limitations as sources of error
  • The nature of error and error management
  • Culture and communications
  • Expert decision-making
  • Training in using specific behaviors and
    procedures as countermeasures against threat and
    error
  • Briefings
  • Inquiry
  • Sharing mental models
  • Conflict resolution
  • Fatigue and alertness management
  • Analysis of incidents and accidents
  • both positive and negative aspects

39
  • The University of Texas
  • Human Factors Research Project
  • www.psy.utexas.edu/HumanFactors
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