Error_ Stress and Teamwork in Aviation and Medicine by linzhengnd

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									  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
                   Outline
•   Aviation’s approach to safety and error
•   Countermeasures
•   Human factors training (CRM)
•   Assessing operational safety (UT)
•   Automation in aviation
•   Transfer of these technologies to medicine
    Why aviation?
• IOM report
• Safety is super-ordinate
  goal
• Teamwork is essential
• Risk varies from low to
  high
• Threat & error come from
  multiple sources
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
        Safety in Aviation
• Safety department (commercial)
  – Training, ASAP
• Base flight saftey (military)
• NASA
  – ASRS
• FAA
  – Safety regualtion
  – Research
  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
   Aviation countermeasures
   designed to enhance safety

• Crew Resource Management (CRM)
• Automation
• Proceduralization
  – Standardized training
  – checklists
      Primary Causes of Air Crashes (%)

      Other

        FAA

    Weather

Maintenance

    Airplane

 Flight Crew


               0   10   20   30   40   50   60   70   80
   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
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
     LOSA results - error frequencies
      Decision       6


   Proficiency       5


Communication        6


    Procedural                29


Noncompliance                                54


                 0       20        40         60       80   100
                                   Percent Frequency
        LOSA results - error outcomes


                         6
      Decision
                                                   43

                         5
   Proficiency                                                    69

                         6
Communication                13

                                         29
    Procedural                      23

                                                          54
Noncompliance        2

                 0            20              40           60          80      100
                                  Percent Consequential    Percent Frequency
       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
                   National preferences for
                         automation
    MEXICO
  INDO NESIA
     KO REA
     BRAZIL
        USA
  ARGENTINA
      JAPAN
NEW ZEALAND
      ITALY
   HO LLAND
    BRITAIN
    IRELAND


               1            2       3   4             5
               Dislike automation       Like automation
           Automation
• Large variations in national tendencies
  towards usage
• Individual preferences
• Usability and design concerns
   – Boeing vs. Airbus
• Possibility of loss of flying skills
Transfer of error countermeasures
   from aviation to medicine:

    • CRM in medicine
    • Automation in medicine
     CRM in medicine
• Currently considered for:
  – OR, ER, Hospitals, clinics


• Research at UT
  – Hermann Hospital
     • NICU
  – Kantonspittel Basel
     • OR
  – Incident and accident analysis
    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
        Automation in medicine
•   Management of medication information
•   Patient and lab information management
•   Delivery of anesthesia
•   Critical care monitoring devices
        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… **
               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*
   The University of Texas
Human Factors Research Project
                URL:
  www.psy.utexas.edu/psy/helmreich/n
              asaut.htm

								
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