National Aeronautics and Space Administration “threat and error” model applied to pediatric cardiac surgery: Error cycles precede ∼85% of patient deaths

Hickey, Edward; Nosikova, Yaroslavna; Pham-Hung, Eric; Gritti, Michael; Schwartz, Steven M.; Caldarone, Christopher A.; Redington, Andrew N.; Arsdell, Glen S. Van

doi:10.1016/j.jtcvs.2014.10.058

Cited by 20 publications

(30 citation statements)

References 15 publications

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“…Aviation-safety investigators have operationalized Reason's (1990) "Swiss cheese" accident-causation model (Fig. 2) in recognition that failure is inevitable in complex systems (Helmreich & Merritt 2000;Hickey et al 2015); failure rarely has a single cause (Reason 1995); human error is implicated in the majority of accidents involving technological systems (Duffey & Saull 2003); and attributions of blame drive errors underground and limit learning opportunities (Reason 2000). For example, accepting that human error may compromise all systems, commercial airline flight-crew training intentionally does not set goals for zero errors, but rather zero accidents, an achievable goal through the active process of mitigating human error when it occurs (United Airlines 2016) and one that shifts blame away from individuals.…”

Section: Definitions Of Failurementioning

confidence: 99%

Black swans, cognition, and the power of learning from failure

Catalano

Redford

Margoluis

et al. 2018

Conservation Biology

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Failure carries undeniable stigma and is difficult to confront for individuals, teams, and organizations. Disciplines such as commercial and military aviation, medicine, and business have long histories of grappling with it, beginning with the recognition that failure is inevitable in every human endeavor. Although conservation may arguably be more complex, conservation professionals can draw on the research and experience of these other disciplines to institutionalize activities and attitudes that foster learning from failure, whether they are minor setbacks or major disasters. Understanding the role of individual cognitive biases, team psychological safety, and organizational willingness to support critical self-examination all contribute to creating a cultural shift in conservation to one that is open to the learning opportunity that failure provides. This new approach to managing failure is a necessary next step in the evolution of conservation effectiveness.

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Section: Definitions Of Failurementioning

confidence: 99%

Black swans, cognition, and the power of learning from failure

Catalano

Redford

Margoluis

et al. 2018

Conservation Biology

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“…The aviation industry holds Six Sigma (nearly perfect) safety records, because it uses the system approach, deals with errors non‐punitively yet proactively, and reduces the consequences of error before escalation. This way of reporting and managing error results in a ‘just culture’, where aviation professionals feel confident to report events (even their own mistakes), by promoting balanced accountability for individuals and organizations responsible.…”

Section: Resultsmentioning

confidence: 99%

Legal perspectives on black box recording devices in the operating environment

Dalen

Legemaate

Schlack

et al. 2019

British Journal of Surgery

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Background A video and medical data recorder in the operating theatre is possible, but concerns over privacy, data use and litigation have limited widespread implementation. The literature on legal considerations and challenges to overcome, and guidelines related to use of data recording in the surgical environment, are presented in this narrative review. Methods A review of PubMed and Embase databases and Cochrane Library was undertaken. International jurisprudence on the topic was searched. Practice recommendations and legal perspectives were acquired based on experience with implementation and use of a video and medical data recorder in the operating theatre. Results After removing duplicates, 116 citations were retrieved and abstracts screened; 31 articles were assessed for eligibility and 20 papers were finally included. According to the European General Data Protection Regulation and US Health Insurance Portability and Accountability Act, researchers are required to make sure that personal data collected from patients and healthcare professionals are used fairly and lawfully, for limited and specifically stated purposes, in an adequate and relevant manner, kept safe and secure, and stored for no longer than is absolutely necessary. Data collected for the sole purpose of healthcare quality improvement are not required to be added to the patient's medical record. Conclusion Transparency on the use and purpose of recorded data should be ensured to both staff and patients. The recorded video data do not need to be used as evidence in court if patient medical records are well maintained. Clear legislation on data responsibility is needed to use the medical recorder optimally for quality improvement initiatives.

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“…5 The principles of safety training in aviation are based on a "threats and errors" model which summarizes the interplay of factors that could potentially lead to a catastrophe. 6 According to this model, errors are preceded by a threat, which is any factor that causes deviation from normal conditions. In this case, the SVC cannula was placed outside the surgical field, which was an adaptation for the minimally invasive procedure and different from the routine for conventional cardiac surgical cases.…”

Section: Discussionmentioning

confidence: 99%

Lessons from aviation - the role of checklists in minimally invasive cardiac surgery

et al. 2015

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We describe an adverse event during minimally invasive cardiac surgery that resulted in a multi-disciplinary review of intra-operative errors and the creation of a procedural checklist. This checklist aims to prevent errors of omission and communication failures that result in increased morbidity and mortality. We discuss the application of the aviation -led "threats and errors model" to medical practice and the role of checklists and other strategies aimed at reducing medical errors.

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National Aeronautics and Space Administration “threat and error” model applied to pediatric cardiac surgery: Error cycles precede ∼85% of patient deaths

Cited by 20 publications

References 15 publications

Black swans, cognition, and the power of learning from failure

Black swans, cognition, and the power of learning from failure

Legal perspectives on black box recording devices in the operating environment

Lessons from aviation - the role of checklists in minimally invasive cardiac surgery

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