Have we gone too far in translating ideas from aviation to patient safety? No
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.c7310 (Published 14 January 2011) Cite this as: BMJ 2011;342:c7310
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Healthcare does have a lesson or two to learn from teams and
professionals working is high risk situations. As medical mistakes in
these circumstances have most detrimental effects, it is not surprising
that peri-operative, trauma and resuscitation healthcare have been the
prime focus of crew resource management (CRM) derived from military and
aviation industry. However, optimal teamwork in healthcare goes beyond
working together as a team during (semi)acute, stress full situations.
Modern healthcare teams are adaptive, sometimes even creative groups of
professionals that have one common goal: providing the best possible
healthcare. As medical teamwork will increasingly be across institutions
even 'long distance' by means of using e-health communication techniques,
cooperation between medical, nursing, social and informal care
professionals / care givers requires a new approach in training and
learning how to adapt best to changing circumstances.
As some use aviation pilots or military personnel as inspiration for
teamwork improvement, others seem to be a step further. Over 3 years ago
the TeamSTEPPS curriculum (http://teamstepps.ahrq.gov/) was launched in
the US, followed by the introduction in Australia and recently the
Netherlands (www.teamworkindezorg.nl). This suite of teamwork training
modules helps generate change within multidisciplinary healthcare teams to
a culture of continuous improvement. This promise is funded on knowledge
and science exceeding ?old school? CRM: clinical microsystems, human
factors, change management, project management, product-line industry
(e.g. Lean/SixSigma), business, psychology, to name a few.
To cope with increasing challenges we are facing in healthcare, we need
more rigorous methods overarching our 'medical comfort zone'. Also, can
our patients wait for the same evidence base that we are taught to find
necessary for adopting new medical interventions or pharmacologic
therapeutic interventions?
Competing interests: dr. Keijser acts as independent consultant to health care organizations and the European Commission.
To paraphrase James Carville, 'It's the analogy, stupid'. The issue
is not going too far or not far enough, it is that the aviation industry
provides a limited analogy for healthcare(1). Health care is a high risk
industry for staff and patients alike. There is no doubt that there are
other potentially high risk industries that have achieved enviable levels
of operational safety, and yes, we can learn from them. And certainly, the
impact of safety failures in aviation affect pilots and passengers alike,
increasing the incentives for good practices. But there is more to it than
that.
In a recent article in the Harvard Business review(2), Groysberg,
Hill and Johnson draw attention to the different operating styles within
the armed forces. They describe how in the Air Force and the Navy, many
day-to-day operations involve very closely coupled, extended, sequences
that need to follow predetermined standard operating procedures if they
are to be done successfully and safely. An error in any one step has
immediate repercussions all along the tightly linked sequence. Those kinds
of sequences are amenable to, and require, constant rehearsal, and a
preoccupation with following standard operations. Flexibility is traded
against safety.
Certainly there are aspects of patient care in fields such as
anesthesia that have similar characteristics.
But Groysberg, Hill and Johnson contrast this with the operating structure
of the Marines, which is essentially modular in nature, with
interdependent, largely autonomous units within units working in a
coordinated but flexible manner to achieve the goals set by the commanders
for the mission. They quote the military aphorism 'No plan survives first
contact with the enemy'. This could easily be replaced with not treatment
plan survives first contact with the elderly patient with multiple primary
conditions and comorbidities.
Tightly linked, rehearsable, checklistable, sequences in health care
are relatively uncommon in comparison to care delivered by a complex inter
-action of more or less well coordinated modular groups of nurses within
wards, doctors within teams, teams within units, units within
institutions, and institutions within communities. This is especially
relevant for the health care we are providing now to our aging
populations, a task that will only increase. So maybe the next step in
patient safety is to move from airplanes to thinking about sending in the
marines?
References
1 Gaba DM. Have we gone too far in translating ideas from aviation to
patient safety? No BMJ 2011; 342:c7310
2 Groysberg B, Hill A, Johnson T. Which of these people is your future
CEO? The different ways military experience prepares managers for
leadership HBR Nov 2010
Competing interests: No competing interests
Gaba contends that the safety record of commercial aviation is
unmatched in healthcare even for elective care [1]. He quotes a figure for
US airline scheduled services (2000-9) of 0.17 fatal accidents per million
departures. Of course, this definition minimises the human impact and he
goes on to admit that many lives are at risk on each flight. With 30-300
passengers per plane, the risk is 5-50 deaths per million passenger trips.
This is low compared with many of the risks inherent in clinical practice
and daily life [2]. However, contrary to his assertion, this safety record
has been equalled in medicine. Radiotherapy is a potentially dangerous and
complex elective intervention whose risks have previously been highlighted
in the BMJ [3]. It carries a risk of death from erroneous delivery of 2-15
per million courses of treatment [4]. This has been achieved by standard
operating procedures, close attention to detail and a system of multiple
checks [5]. In addition, the UK has long had a compulsory system to report
doses "greater than intended" and now has a comprehensive voluntary
reporting system for near misses which emulates that of aviation. We seek
further reduction in errors and incidents and our approach has in part
been informed by that of the airline industry [5].
1. Gaba DM. Have we gone too far in translating ideas from aviation
to patient safety? BMJ 2011; 342:c7310
2. Munro AJ. Hidden danger, obvious opportunity: error and risk in
the management of cancer. British Journal of Radiology. 2007; 80: 955-66
3. Donaldson L. Reducing harm from radiotherapy. BMJ 2007; 334: 272.
4. Williams MV and Frew TL. How dangerous is radiotherapy? Int J
Radiat Oncol Biol Phys 2011 in press.
5. The Royal College of Radiologists, Society and College of
Radiographers, Institute of Physics and Engineering in Medicine, National
Patient Safety Agency, British Institute of Radiology (2008) Towards Safer
Radiotherapy. The Royal College of Radiologists, London. Available at:
www.rcr.ac.uk/index.asp?PageID=149&PublicationID=281
Competing interests: No competing interests
Let's fly with it!
Rogers is right in saying that simulators in medicine don't offer the
same degree of realism as in aviation (1). But every little bit helps. If
aviation still has that glamorous aura about it to make anodyne concepts
like 'teamwork' and 'ergonomics' lively and appealing again, let's 'fly'
with it.
In the 2009 report the CMO (2) - who apparently loves planes too -
wrote that simulation-based training offered an important route to safer
care for patients. He argued that it offers opportunities for continual
exposure to develop and reinforce safe 'habits' so that when people
confront an emergency 'they do so with the experience of detailed
rehearsal' (p51). This refers to individuals mastering procedures. It fits
too with the use of checklists, and protocols. But perhaps it fails to
expand on the potential of simulation-based training in medicine to
recreate complex dynamics and conditions for 'new' learning.
Simulation-based training can also offer opportunities to teams for
knowledge 'production' rather than 'reproduction'. The St Georges Advanced
Patient Simulator centre in London (GAPS) offers an interesting model. The
idea is that learning is seen as embedded in a socialisation process of
different people with different skills, knowledge, and philosophies of
care. Teams in healthcare are often unstable & heterogeneous. For this
reason training privileges the dynamics of interprofesional collaboration
over individual rehearsal. Here, effective teamwork, decision-making and
patient safety are entwined. At the end of the day an anonymous self-
reporting 'incident' tool for all team members facilitates a culture of
review, transparency and speaking up. It also allows trainers to analyze
critical issues for future training & feedback. Another tip from the
skies!
Competing interests: No competing interests