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Error, Stress and Teamwork in Aviation and Medicine

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Error, Stress and Teamwork in Aviation and Medicine. Summit 2000 ... Boeing vs. Airbus. Possibility of loss of flying skills. Transfer of error countermeasures ... – PowerPoint PPT presentation

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Title: Error, Stress and Teamwork in Aviation and Medicine


1
Error, Stress and Teamwork in Aviation and
Medicine
  • Summit 2000 - Better Outcomes Through
  • Medication Healthcare Collaboration
  • 29 November, 2000
  • Dave Musson, MD
  • The University of Texas Human Factors Research
    Project

2
Outline
  • Aviations approach to safety and error
  • Countermeasures
  • Human factors training (CRM)
  • Assessing operational safety (UT)
  • Automation in aviation
  • Transfer of these technologies to medicine

3
Why aviation?
  • IOM report
  • Safety is super-ordinate goal
  • Teamwork is essential
  • Risk varies from low to high
  • Threat error come from multiple sources

4
Human error in Aviation and Medicine
  • Errors Stem from Human Limitations
  • Limited memory capacity
  • Limited processing capacity
  • Limits imposed by stressors
  • Limits imposed by fatigue and other physiological
    factors
  • Poor group dynamics
  • Cultural influences

5
Safety in Aviation
  • Safety department (commercial)
  • Training, ASAP
  • Base flight saftey (military)
  • NASA
  • ASRS
  • FAA
  • Safety regualtion
  • Research

6
Aviation approach to error
  • System approach to system error
  • Organized development of error countermeasures
  • Research and data collection on an ongoing basis
    in support of safety

7
Aviation countermeasures designed to enhance
safety
  • Crew Resource Management (CRM)
  • Automation
  • Proceduralization
  • Standardized training
  • checklists

8
Primary Causes of Air Crashes ()
9
Crew Resource Management
  • Mandated by FAA
  • Formal training in
  • Leadership, Communication
  • Information management
  • Issues in CRM
  • Resistance on the part of some pilots
  • Failure of early programs
  • Multiple generations of CRM - slow process

10
Line Operations Safety Audit (LOSA)
  • Observation of actual line operations (4000 to
    date)
  • Structured observation methods
  • Trained observers (UT and airline)
  • Non-jeopardy conditions
  • Non-punitive approach

11
LOSA results - error frequencies
12
LOSA results - error outcomes
13
Automation in aviation
  • Introduced to improve safety
  • Has solved one set of problems
  • Produced new types of errors
  • largely unanticipated
  • Other problems associated with automation
  • cultural acceptance, individual preferences

14
National preferences for automation
15
Automation
  • Large variations in national tendencies towards
    usage
  • Individual preferences
  • Usability and design concerns
  • Boeing vs. Airbus
  • Possibility of loss of flying skills

16
Transfer of error countermeasures from aviation
to medicine
  • CRM in medicine
  • Automation in medicine

17
CRM in medicine
  • Currently considered for
  • OR, ER, Hospitals, clinics
  • Research at UT
  • Hermann Hospital
  • NICU
  • Kantonspittel Basel
  • OR
  • Incident and accident analysis

18
CRM in Medicine - areas of concern
  • Transferability of human factors programs (CRM)
  • between airlines - difficult
  • between countries - very difficult
  • into medicine - ?
  • Domain specific requirements
  • Must be supported by ongoing research
  • Modification as indicated by research
  • Not a simple process

19
Automation in medicine
  • Management of medication information
  • Patient and lab information management
  • Delivery of anesthesia
  • Critical care monitoring devices

20
Automation in medicine - potential areas of
concern
  • Data entry errors - the most common error we
    observe in aviation
  • New set of skills required
  • training, acceptance, transfer between systems
  • Usability issues
  • proprietary differences, standardization
  • Unforseen errors…

21
Summary points
  • Aviation has had a long history of reducing error
    at the system level - gradual change
  • Many improvements, but not without problems
  • Human resource management (CRM) as a means of
    improving safety
  • potential benefits but also problems
  • Automation - error reduction, but with new errors
  • The need for data collection to assess
    interventions

22
The University of Texas Human Factors Research
Project
  • URL www.psy.utexas.edu/psy/helmreich/nasaut.htm
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