Managing Threat and Error in Aviation and Medicine

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Managing Threat and ErrorinAviation and Medicine

• Robert Helmreich, PhD, FRAeS
• The University of Texas
• Human Factors Research Project
• College of Liberal Arts Foundation
• Advisory Council
• April 8, 2005

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University of Texas Human Factors Research Project

• Research into
• Personality and performance
• Individual and team performance
• Human error
• Living in isolation and confinement
• National, organizational, and professional
  cultures

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Threat and Error in Aviation

• Accident investigation
• Flightcrew performance
• Confidential incident reporting system
• Selection
• Personality and performance

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• Astronaut Selection
• Research
• Personality and performance

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Healthcare Research

• University of Texas Center of Excellence in
  Patient Safety Research
• Incident reporting
• Team behavior
• Professional culture of MDs
• Human error in the Intensive Care Unit
• Analysis of videotaped resuscitations

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Healthcare Research

• Safety is primary goal
• But cost drives decisions
• Technological innovation
• Multiple sources of threat
• Second guessing after disaster
• Air crashes
• Sentinel events (patient death)
• Teamwork is essential

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Why Teamwork Matters

• Most endeavors 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 focuses on technical, not
  interpersonal, skills

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Getting surgeons, anesthesiologists, and nurses
to work as a team is like herding cats
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What Determines Team Performance and Team Error

• Individual knowledge and skill
• Organizational characteristics
• Team composition
• Culture

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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 a factor in accidents and incidents in
  aviation and medicine

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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

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Organizational Culture and Safety

• Investigation of air crashes shows poor
  organizational culture to be a precursor of
  disaster
• Lack of safety concerns
• Operational pressures
• Poor leadership
• Conflict with management
• Negative organizational climate
• Morale/job satisfaction

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Threats to Safety in Medicine
Threats are events and errors outside the
individual or team that require active management
for safety
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Threats to Safety in Medicine
Organizational 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 Proficiency Fatigue Motivation Cultur
e (Invulnerability)
Patient Primary illness Secondary illness Risk
Factors Atypical response to treatment Ongoing
management
Expected Events and Risks Unexpected Events and
Risks
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Error
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44,000-98,000 deaths/year due to medical error-
Institute Of Medicine Report
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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
• Error is the downside of having a brain

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• In both aviation and medicine professionals must
  deal with technology

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Newer technology doesnt eliminate error
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Problems at the Interface Between Teams

• We have observed many instances of conflict
  between surgical and anesthesia teams in the
  operating room

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Error
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Antidotes toThreat and ErrorHow can we improve
team performance?
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Building a Safety Culture What Organizations Can
Do

• Define a clear policy regarding human error
• Accept error but not intentional non-compliance
• Institute formal procedures where appropriate
• Recognize the dangers in fatigue
• Use protected confidential reporting systems to
  uncover threats
• Analyze events using threat and error template
• Provide formal training in threat and error
  management
• Make personality a critical factor in selection
  and qualification of frontline staff

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Does Research Make a Difference?

• Airlines have made changes in operations and
  procedures and introduced new training based on
  findings
• Hospitals have initiated confidential reporting
  systems and are giving training based on aviation
  findings and research into team error
• UT personality constellations used in selection
  for safety-critical professions

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Our research team

• Michelle Harper
• Chris Henry
• Major Tom Hughes, PhD
• James Klinect
• Ashleigh Merritt, PhD
• Lou Montgomery
• John Wilhelm
• Undergraduate honors students

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