# Presentation: 007661

## HUMAN ERROR IN AVIATION OPERATIONS:ideas for the transfusion medicine arena

**Loukia D. Loukopoulos**
**R. Key Dismukes**
- Human Factors Division
- NASA Ames Research Center
- Moffett Field, CA, USA

**APRIL 2002**

## OUTLINE

**Human error: definition and scope**
**Error in aviation**
**approach: past and current**
**learning from past mistakes**
**monitoring current system**
**interventions**
**cognitive themes**
**Error in (transfusion) medicine**
**new era of thought**
**learning from past mistakes**
**monitoring current system**
**interventions**
**Strategies for reducing error**

## ERROR: Definition

**A failure arising from **
**an action that was not completed as intended **
**a plan for action that was inadequate to begin with**
_**Slips & Lapses (skill-based)**_
**occur at storage or execution stage (memory and attention errors)**** **
_**Mistakes**_** (rule- and knowledge-based)**
**occur at judging or inference stage (planning errors)**
***(Reason, 1990)***** **
**Ultimate outcome (detected or undetected, mitigated or leading to further errors, catastrophic or inconsequential) is ****not part of the definition**

## Slide 4

**Notes:**
Fedex 14 MD-11, crash during landing, Newark, NJ
Newark, July 1997
Exxon Valdez, 1989
Chernobyl, 1986
USS Greeneville, 2001

## ACCIDENTS

**ACCIDENTS**

**INCIDENTS**

**ERRORS (UNREPORTED**
**OCCURRENCES) **

**Notes:**
Errors  = building blocks of tomorrow’s accidents and incidents; esp. when they happen in conjunction with other blocks in this part of pyramid

## STATISTICS on ERROR

_**Aviation (U.S. air carriers)**_
**2 errors per flight**** ****(LOSA data, 2001)**
**<0.3 fatal accidents/ 100,000 flight hours annually**
**60-80% of accidents involve human error ****(Foushee 1984)**
_**Hospital admissions**_
**1,000,000 people injured/yr by errors in treatment at hospitals in US ****(Marx,2001)**** **
**44,000-98,000 errors are fatal ****(= 1 jumbo jet crash per day)**** ****(IOM report 1999, Leape, 1999)**** **
**UK: 40,000 errors are fatal**** ****(QuIC report, 2000)**
_**Drug administration**_** **
**1 in 5 injuries or deaths annually in hospitals ****(AHRQ 1991)**
**7,000 deaths annually ****(QuIC report, 2000)**
_**Anesthesia**_** **
**2,000-10,000 deaths/yr ****(Cooper, Newbower, & Kitz, 1985)**
**exposure similar to that of aviation (20x107 passenger boarding vs. 20x106 anesthetics)**
_**Surgery**_
**48-66% of adverse events at hospital ****(Gawande, 2001)**
_**ICU**_
**2 errors per day ****(Leape, 1994)**** **
_**Emergency medicine**_
**8-10% disagreement in interpretation of radiographs by emergency physicians and radiologists (later) ****(Espinosa & Nolan, 2000)**

**Notes:**
Error in 60% of flights (LOSA data, 2001)

Measured vs. estimated rates
Definitions: error, adverse events, fatal error 
Hospital admissions vs. procedures
Transfusion errors: including OR transfusions?
Source: random sample of reports, all reports, direct observation?
Preventable events?
Most often, only fatal errors reported - what is the baseline? 

hospital errors: diagnostic, equipment failure, infections, transfusions, misinterpretation of orders
UK: 11% of patients in hospital experienced an adverse event; 50% were preventable (Vincent ,Neale, & Woloshynowych, 2001)
3000 mistakes in less than 2 years at VA hospitals in US, 1 in 4 mistakes fatal) (VA Medical Inspector, 1999) 
ICU: 2 errors per day (= 2 dangerous landings per day at ORD, 32,000 checks deducted from the wrong banking account per hour)

Currently almost 20 States have implemented mandatory reporting systems to improve patient safety (QuIC report, 2000)

Gawande: using data from Harvard medical practice study, 1992; UT/CO study, 1999

## STATISTICS on ERROR

_**Blood transfusion**_
**1 in 12,000 transfusions****                                                                            1 in 33,000 results in ABO-incompatible red blood cell transfusion**** ****(Linden, Paul, & Dressler, 1992)**
**1 in 19,000 transfusions ****(Linden, Wagner, Voytovich, & Sheehan, 2000)**
**Sources of error****: misidentification of patient or blood at bedside;     wrong unit issued; phlebotomy error**
**Contributing factors****: same or similar names, use of oral vs. computer orders, rush situations, simultaneous handling of specimens, interruptions**
**1 per 16,000 transfusions in UK**** ****(Williamson, Cohen, Love, et al., 2000)**
**      ****Risk of transfusion-associated infection = 1 in 300,000**
**1 in 600,000 to 800,000 transfusions result in fatal HTR ****(hemolytic transfusion reaction) ****(Linden, Paul, & Dressler, 1992, Sazama, 1990) **
**1 in 2,000,000 transfusions result in fatal HTR**** ****(Linden, Wagner, Voytovich, & Sheehan, 2000)**
**       ****Risk of transfusion-associated HIV infection = 1 in 1,000,000**

**Notes:**
1 in 200,000 components transfused in hospitals (est?) (JHACO)

## ERROR IN AVIATION

## PAST APPROACH

**Name and blame**
**If pilot/crew had followed training and SOPs ****(standard operating procedures)**** he or she would not have made an error**
**Pilot/crew was not careful enough**
**Self-blame**
**How could this have happened to me?!**
**I was not paying enough attention**
**Self-denial**
**This would never happen to me (us)**
**This will never happen to me (us) again**
**Why?**
**Easier to point the finger**
**Hindsight bias**
**Apparently isolated incidents**
**Emotionally (politically) satisfying**
**Lack of understanding of human cognitive processes**
**Blame and punish (or at least blame and train)**
**Quick-fix approach**

***ERROR IN AVIATION***

## SHIFT IN APPROACH

**“****Grounding” of aircraft upon return from mission (WWII pilots)**
**Fitts & Jones, 1947: features of airplane cockpits**
**Shift focus from operator to system**
**Simply trying hard will not prevent errors**
**Error is a symptom**
**Accidents result from combination of events/factors**
_**Active errors**_**: whose effects are felt almost immediately**
**performance of the “front-line” operators (sharp end)**
_**Latent errors**_**: whose effects may be hidden for long, becoming evident only when they combine with other factors**
**management leadership, philosophy, response**
***(Reason, 1990)***

***ERROR IN AVIATION***

**Notes:**
WWII pilots “grounded” numerous aircraft post-mission when they pulled the gear instead of the flap handle
Fitts & Jones, 1947: features of airplane cockpits systematically influenced the way in which pilots made errors 
    (handles looked and felt the same and were co-located) 
How many occurrences of an error before we stop blaming the operator and start focusing more on whether the mission, the workplace and/or the procedures need re-design?

Latent: reaction and response to mishaps, philosophy of operations, maintenance, equipment, staffing

## SHIFT IN APPROACH

***SHIFT IN APPROACH***

***ERROR IN AVIATION***

**Notes:**
Can be seen at two levels: slices are elements of production of a complex system
Decision makers (management dealing with balancing productivity and safety; allocates money, equipment, people, time)
Line management (operations, training, maintenance)
Preconditions (condition of equipment, skill of workforce, work schedule)
productive activities (human-machine integration)
Defenses (safeguards against foreseeable hazards)

Or as elements of process within the complex system (e.g., Preflight)
Read and sign paperwork (weather, clearance)
Conduct exterior inspection
Conduct cockpit inspection
Brief cabin crew
Preflight checklist

## SHIFT IN APPROACH

-              L

-          S

- H

**CHECKLIST**
- 1. Xxx  slkj
- 2. xlkdaf;j alsk
- 3. S;lk
- 4. aslkj

- E

**Systems Approach**
**safety does not reside in a person, device, or department,              but emerges from interactions between the system components**

***SHIFT IN APPROACH***

***ERROR IN AVIATION***

**Notes:**
SHEL model: 
Software: procedures, manuals, checklists, symbology etc
Environment: working conditions, weather
Hardware: aircraft and components
All surround Liveware: human element (pilot, ATC, ground staff)
Whole system operates within the context of broad social, political, economical and natural constraints that are usually beyond the control of the Liveware.

## Cannot eliminate human error 
Error is not deterministic but probabilistic
Humans have cognitive limitations
Focus on making system less error prone and more error tolerant

Activities directed at improving safety:
Technology: e.g., GPWS, TCAS, navigation aids, landing aids
Research: basic and applied, databases
Operations: standardized, explicit procedures (flows, checklists)
Training: standardized, recurring, incl. performance evaluation
Regulation: inspection, enforcement
All above aspects: include human performance issues (e.g., fatigue)

Dramatic reduction of worldwide aviation accident rate since 1950

**Error is not deterministic but probabilistic**
**Humans have cognitive limitations**
**Focus on making system ****less error prone**** and ****more error tolerant**
**Activities directed at improving safety:**
**Technology: e.g., GPWS, TCAS, navigation aids, landing aids**
**Research: basic and applied, databases**
**Operations: standardized, explicit procedures ****(flows, checklists)**
**Training: standardized, recurring, incl. performance evaluation**
**Regulation: inspection, enforcement**
**All above aspects: include human performance issues ****(e.g., **_**fatigue**_**)**
**Dramatic reduction of worldwide aviation accident rate since 1950**

***CURRENT APPROACH***

***ERROR IN AVIATION***

**Notes:**
Error is not deterministic (cannot predict when it will happen), but probabilistic (can predict the factors that increase its probability)

Unique human capabilities – same that make human vulnerable
e.g., ability to divide attention

Advanced Qualification Program (AQP): voluntary alternative to the traditional regulatory requirements, reviewed and approved by FAA, mandatory elements
About 25 carriers are now training under an AQP program

Focus on making system less error prone (less likely to create conditions that could result in human error) and more error tolerant (more capable of withstanding errors without catastrophic results)

## ACCIDENT INVESTIGATIONS

**All aviation accidents on U.S. soil investigated by one entity (NTSB) since 1967**
**large (>150 page) “standardized” comprehensive report**
**Operations, Structures, Powerplants, Systems, Air Traffic Control, Weather, Survival Factors, Human Performance**
**accumulation of large body of data – enables monitoring of aviation system and compilation of reports**
**reports are published, publicly available, discussed widely **
**shift in thinking is evident!**
**Most accidents attributed to error  ****(NSTB1995  report on 1978-1990 major US air carrier accidents)**
**Errors committed by flight crew causal or contributing factors in  **
**42.3% of all (fatal and non-fatal) accidents**
**55.8% of fatal accidents **
**Error types: procedural (24%), monitoring/challenging (23%), and tactical/decision (17%)**

***LEARNING from PAST MISTAKES***

**Notes:**
Procedural: fail to make callouts, fail to initiate checklists, improper conduct of checklists
Tactical decision: failure to execute a go-around, or missed approach
Monitoring: failure to challenge a tactical decision error

## CHIRP (U.K.), SECURITAS (Canada), CAIRS (Australia), VARS (Russia), TACARE (Taiwan), KCAIRS (Korea)
GAIN (Global Aviation Information Network, FAA)
Aviation Safety Reporting System (ASRS)
1976 (NASA/FAA)
Voluntary submissions by users of the National Aviation  System
Reports of unsafe occurrences and hazardous situations
Guaranteed confidentiality and limited immunity                          (if submitted within 10 days accidents and criminal activities not protected)
De-identified database publicly available
Identifies deficiencies in National Airspace System
Provides data for planning future procedures, operations, facilities, equipment
Output: Alert Messages, Callback, pilot newsletters, research articles, search requests, FAA & NTSB quick responses
496,000 reports (average 2860 reports/month)
>200 search requests in CY2000

**GAIN (Global Aviation Information Network, FAA)**
**Aviation Safety Reporting System (ASRS)**
**1976 (NASA/FAA)**
**Voluntary**** submissions by users of the National Aviation  System**
**Reports of unsafe occurrences and hazardous situations**
**Guaranteed ****confidentiality**** and limited immunity                          ****(if submitted within 10 days accidents and criminal activities not protected)**
**De-identified database ****publicly**** ****available**
**Identifies deficiencies in National Airspace System**
**Provides data for planning future procedures, operations, facilities, equipment**
**Output****: Alert Messages, Callback, pilot newsletters, research articles, search requests, FAA & NTSB quick responses**
**496,000 reports (average ****2860 reports/month****)**
**>200 search requests in CY2000**

***INCIDENT REPORTS***

***LEARNING from PAST MISTAKES***

## Reasons for success
Owned and managed by non-regulatory agency
Voluntary
No-penalty; immunity = incentive for timely reporting
Broad information sources 
pilots, mechanics, flight attendants, air traffic controllers, ground personnel 
air carrier, general aviation, cargo, military
manufacturers, airport operators
Regular feedback to aviation community
Not anonymous, allows for follow-up (until de-identification)

Led to significant regulatory changes (fatigue, sterile cockpit)

Lessons learned
Reporting bias (who submits and what gets reported)
Requires powerful analytic tools for data-mining (APMS, QUORUM)
Private ownership allows for even faster responses - ASAP

**Owned and managed by non-regulatory agency**
**Voluntary**
**No-penalty; immunity = incentive for timely reporting**
**Broad information sources **
**pilots, mechanics, flight attendants, air traffic controllers, ground personnel **
**air carrier, general aviation, cargo, military**
**manufacturers, airport operators**
**Regular feedback to aviation community**
**Not anonymous, allows for follow-up (until de-identification)**
**Led to significant regulatory changes (fatigue, sterile cockpit)**
**Lessons learned**
**Reporting bias (who submits and what gets reported)**
**Requires powerful analytic tools for data-mining (APMS, QUORUM)**
**Private ownership allows for even faster responses - ASAP**

***INCIDENT REPORTS***

***LEARNING from PAST MISTAKES***

**Notes:**
Reporting bias: no baseline, must report all errors and events that could have led to errors 
APMS
develop and document the methodologies, algorithms, and procedures for data management and analyses to enable users to interpret easily their implications regarding the safety and efficiency of operations. APMS is intended to be a developer of system guidelines and an engine of technology transfer to the U.S. aviation industry and to the vendor community, that serves it. It has been recognized as key to the future development of the system-wide monitoring capability of the Aviation Safety Program and for the FAA's GAIN program. 
QUORUM
To support the analysis and retrieval of ASRS reports based on the narrative text field contained within each report, a suite of text processing methods called QUORUM has been developed. QUORUM is useful for modeling situations that are described in narrative accounts of incidents and accidents. Further, it can use these models to identify prominent yet distinguishing characteristics of the situations, and can relevance-rank collections of incidents according to these representative characteristics. 
ASAP
An in-house ASRS: developed, shared, and dealt with only within airline
Currently in use by 16 US airlines
Voluntary reports of safety issues, within 24 hours, not involving criminal activity
Reviewed by airline event Review committee

## Line Operations Safety Audit (LOSA) (Helmreich, UTexas, 1992)
Jumpseat observations of crew during regularly scheduled flights
Demographics
Attitude/Perception
Safety interview
Flight description: narrative, threats, operational complexity
Crew performance: errors and violations, undesired aircraft states, technical data, threat and error management

Utilized by 20 air carriers since 1992 (some now doing own LOSAs)
Data used to
assess system safety and id issues for action
provides airlines with feedback on their own operations
Findings
Average of 2 errors per (routine) flight
77% errors inconsequential; 64% errors undetected by crew

**Jumpseat observations of crew during ****regularly scheduled**** flights**
**Demographics**
**Attitude/Perception**
**Safety interview**
**Flight description: narrative, threats, operational complexity**
**Crew performance: errors and violations, undesired aircraft states, technical data, threat and error management**
**Utilized by 20 air carriers since 1992 ****(some now doing own LOSAs)**
**Data used to**
**assess system safety and id issues for action**
**provides airlines with ****feedback on their own operations**
**Findings**
**Average of 2 errors per (routine) flight**
**77% errors inconsequential; ****64% errors undetected by crew**

***AUDITS***

***MONITORING CURRENT SYSTEM***

**Notes:**
Non-punitive!
LOSA form:
Demographics
Attitude/Perception
Safety interview
Flight description: narrative, threats, operational complexity
Crew performance: errors and violations, undesired aircraft states, technical data, threat and error management

## Flight Operational Quality Assurance (FOQA)
First established in Europe and Asia
Now utilized by 33 non-US and 4 US airlines
Obtain and analyze data recorded in flight
up to 500 aircraft system parameters
determine if pilot, aircraft systems, or aircraft itself deviates from typical operating norms 
measure deviations from up to 80 predefined events                          (= exceedances) (e.g., descent rate during approach)
identify problems in normal operations and correct them before they contribute to incidents or accidents
periodically, airlines aggregate exceedances over time to determine and monitor trends

**First established in Europe and Asia**
**Now utilized by 33 non-US and 4 US airlines**
**Obtain and analyze data recorded in flight**
**up to 500 aircraft system parameters**
**determine if pilot, aircraft systems, or aircraft itself deviates from typical operating norms **
**measure deviations from up to 80 predefined events                          (= ****exceedances****) ****(e.g., descent rate during approach)**
**identify ****problems in normal operations**** and correct them before they contribute to incidents or accidents**
**periodically, airlines aggregate exceedances over time to determine and monitor ****trends**

***IN-FLIGHT DATA***

***MONITORING CURRENT SYSTEM***

## Crew Resource Management (CRM) (5th generation)
shift from training only technical aspects of flying
address individual and team behavior and attitudes
consider human performance limiters (fatigue, stress) and nature of human error
suggest behavioral strategies as countermeasures 
leadership
communication
briefings
monitoring
decision making
review and modification of plans

Shift to Error Management Training
Recognize potential threats, detect errors, manage error outcome

**shift from training only technical aspects of flying**
**address individual and team ****behavior**** and ****attitudes**
**consider human performance limiters (fatigue, stress) and nature of human error**
**suggest behavioral strategies as countermeasures **
**leadership**
**communication**
**briefings**
**monitoring**
**decision making**
**review and modification of plans**
**Shift to Error Management Training**
**Recognize**** potential threats, ****detect**** errors, ****manage**** error outcome**

***TRAINING: classroom***

***INTERVENTIONS***

## Line Oriented Flight Training (LOFT)
Full-mission simulation of specially-designed scenaria
normal operations
challenging situations (e.g., weather diversions, equipment failures)
Instructor evaluates both flying skills and behavioral markers (CRM)
Pilots receive feedback about individual and team performance

Challenges
More effective if tailored to reflect operations specific to organization
Must be followed by effective debrief (Dismukes, McDonnell, & Jobe, 2000)
Should include realistic concurrent task demands: interruptions, distractions, delays

**Full-mission simulation of specially-designed scenaria**
**normal operations**
**challenging situations ****(e.g., weather diversions, equipment failures)**
**Instructor evaluates both flying skills and behavioral markers (CRM)**
**Pilots receive feedback about individual and team performance**
**Challenges**
**More effective if ****tailored**** to reflect operations specific to organization**
**Must be followed by effective ****debrief**** ****(Dismukes, McDonnell, & Jobe, 2000)**
**Should include realistic concurrent task demands: ****interruptions****, distractions, delays**

***TRAINING: simulator***

***INTERVENTIONS***

## It is the same cognitive mechanisms that afford humans unique capabilities and skills that give rise to limitations and vulnerabilities

Interruptions & Distractions
defer/delay tasks (prospective memory)
disruption or removal of environmental triggers

Automaticity
goal and result of training
no control over timing and accuracy
habit capture

Expectations and assumptions

Sidetracking
Preoccupation

**Interruptions & Distractions**
**defer/delay tasks (prospective memory)**
**disruption or removal of environmental triggers**
**Automaticity**
**goal and result of training**
**no control over timing and accuracy**
**habit capture**
**Expectations and assumptions**
**Sidetracking**
**Preoccupation**

***VULNERABILITIES***

***COGNITIVE THEMES***

## TAXI: real life demands

*(compiled observations)*

** **_**FIRST OFFICER**_
- Set flaps
- Request taxi clearance
- Monitor radios
- Receive taxi clearance
- Acknowledge taxi clearance
- Form mental picture of taxi route
- Check for obstacles
- Perform PRETAKEOFF Flow
- Start PRETAKEOFF Checklist
- Monitor radios
- Monitor traffic
- Monitor position on airport chart
- Taxi Checklist complete
- Monitor CA and aircraft movement
- Switch to Tower and monitor
- Receive clearance
- Acknowledge takeoff clearance
- BELOW-LINE flow
- Start BELOW-LINE items
- PRETAKEOFF Check complete

- N1 S
- Stabilizer Trim
- "0" Fuel Weight
- V Speeds
- FMC Preflight
- CDU
- Seatbelt And Harness
- Trim
- Start Levers
- Wing Flaps
- Compass Indicators
- Altimeters
- Pitot Heat
- Engine & Wing Anti-ice
- Engine Start Switches
- Flight Controls
- APU
- Takeoff Briefing

- Attendant Call
- Cockpit Door
- Transponder
- Packs
- Engine Bleed Switches
- Master Caution

**TAKEOFF**

_**CAPTAIN**_** **
- Ask for flaps
- Ask for taxi clearance
- Monitor radios
- Receive taxi clearance
- Form mental picture of taxi route
- Check for obstacles
- Start taxiing
- Perform PRETAKEOFF Flow
- Ask for PRETAKEOFF Checklist
- Monitor radios
- Monitor traffic
- Maintain positional and situational awareness
- Monitor Tower
- Receive clearance
- BELOW-LINE flow
- Ask for BELOW-LINE items
- Line up with runway

***M***
***O***
***N***
***I***
***T***
***O***
***R***

***T***
***A***
***X***
***I***

- Loukopoulos, Dismukes, & Barshi, 2000

**Notes:**
Real life: far from sterile
Forced to CTM
Sheer volume 
Items out of sequence
Additional items
Novel combinations of tasks

Each addition/deferral presents a vulnerable point and creates an opportunity for an error

## TAXI: errors observed  (ASRS reports)

- Stabilizer Trim
- "0" Fuel Weight
- V Speeds
- FMC Preflight
- CDU
- Seatbelt And Harness
- Trim
- Start Levers
- Wing Flaps
- Compass Indicators
- Altimeters
- Pitot Heat
- Engine & Wing Anti-ice
- Engine Start Switches
- Flight Controls
- APU
- Takeoff Briefing

- Attendant Call
- Cockpit Door
- Transponder
- Packs
- Engine Bleed Switches
- Master Caution

** **_**FIRST OFFICER**_
- Set flaps
- Request taxi clearance
- Monitor radios
- Receive taxi clearance
- Acknowledge taxi clearance
- Form mental picture of taxi route
- Check for obstacles
- Perform PRETAKEOFF Flow
- Start PRETAKEOFF Checklist
- Monitor radios
- Monitor traffic
- Monitor position on airport chart
- (Delayed engine start)
- Taxi Checklist complete
- Monitor CA and aircraft movement
- Switch to Tower and monitor
- Receive clearance
- Acknowledge takeoff clearance
- BELOW-LINE flow
- Start BELOW-LINE items
- PRETAKEOFF Check complete

**TAKEOFF**

_**CAPTAIN**_** **
- Ask for flaps
- Ask for taxi clearance
- Monitor radios
- Receive taxi clearance
- Form mental picture of taxi route
- Check for obstacles
- Start taxiing
- Perform PRETAKEOFF Flow
- Ask for PRETAKEOFF Checklist
- Monitor radios
- Monitor traffic
- Maintain positional and situational awareness
- Monitor Tower
- Receive clearance
- BELOW-LINE flow
- Ask for BELOW-LINE items
- Line up with runway

*TAXI: errors observed  **(ASRS reports)*

**Forget to confirm tug clear - **
**taxi into tug**

**Omit - overrun runway hold line**

**Mistook clearance to other aircraft for own - taxi without clearance**

**Confuse position - taxi into ditch**

**CA briefed and FO set wrong flaps for aircraft type - warning horn at takeoff**

**Busy starting engine & running delayed engine xlist and taxi xlist - runway incursion**

**Busy running checklist - **
**force other aircraft to go around**

**Inadvertently hit flip-flop switch - delay**

**APU bleed source - lost both packs in flight - enter pre-stall buffet while troubleshooting**

**Omit or incorrectly set- warning horn at takeoff**

**Omitted checklist and has not restarted engine #1 - delay**

**Misunderstand tower instructions - taxi onto runway w/o clearance**

**Preoccupied with new departure clearance and packs-off operation and omit - aborted takeoff**

**New FO on IOE expected to hear “position and hold” - runway incursion**

**Squawk incorrectly set during preflight - rush and fail to notice error before takeoff**

**Fail to stop when lost  - other aircraft had clearance canceled**

**Forget to turn ignition switch on - overtemp engine**

- Loukopoulos, Dismukes, & Barshi, 2000

## SO WHAT CAN AVIATION TELL US ABOUT ERROR IN (transfusion) MEDICINE?

## AVIATION ~ MEDICINE

**Dynamic environment**
**contrary to training and expectation **
**impossible to capture in written procedures and manuals**
**All phases complex **
**(preflight, pushback, taxi, takeoff, climb, cruise, descent approach, landing, taxi, shut down)**
**(collection, storage, transport, compatibility testing, delivery)**
**High information load**
**detect and interpret cues from multiple sources**
**prioritize demands and responses**
**Concurrent task demands**
**Multi-disciplinary, team situation**
**professional, national, organizational cultures at play (language, values)**
**Increasing interaction with technology and automation**
**Variable workload (hours of boredom, moments of terror) **
***? Training (continuous, evaluative vs. ?)***
***? Risk (multiple passengers + SELF vs. single patient)***
***? Ultimate responsibility (Pilot in Command vs. ?)***

## AVIATION ~ MEDICINE

**Comparison survey of OR + ICU and cockpit**
**Doctors, nurses, fellows, and residents vs. pilots **
**(Sexton, Thomas & Helmreich, 2000)**
**Medical staff more likely to deny the effects of ****fatigue**** on performance (60%) than pilots (26%)**
**Self-ratings of fatigue *****at time of task performance***** show higher rates of denial ****(NASA fatigue studies)**
**94% of pilots and intensive care staff advocated flat ****hierarchies**** vs. only 55% of consultant surgeons**
**Asymmetrical perception of teamwork and ****status**** in team**
**Surgery vs. anesthesia**
**ICU doctors vs. nurses**

**Notes:**
Surgery generally reports good teamwork with anesthesia, but anesthesia staff do not necessary hold a reciprocal perception
ICU doctors report high levels of teamwork with nurses, but nurses do not hold reciprocal perception

## Institute of Medicine report (1999) established national                  goal of reducing the number of medical errors by                       50% over next 5 years
Establish a national focus to create leadership,                      research, tools, protocols to enhance the knowledge                      base about safety
Identify and learn from medical errors through                      mandatory and voluntary reporting systems
Raise standards and expectations for improvements 
Implement safe practices at delivery level

One week later, the President directed a coordination task force to evaluate these recommendations and respond with a strategy 
Feb 2000: endorsed IOM goals  and strategy

**Establish a national focus to create leadership,                      research, tools, protocols to enhance the knowledge                      base about safety**
**Identify and learn from medical errors through                      mandatory and voluntary reporting systems**
**Raise standards and expectations for improvements **
**Implement safe practices at delivery level**
**One week later, the President directed a coordination task force to evaluate these recommendations and respond with a strategy **
**Feb 2000: endorsed IOM goals  and strategy**

***CURRENT APPROACH (U.S.)***

***ERROR IN MEDICINE***

## HOSPITALS
VA PSRS (Patient Safety Reporting System)
mandatory at all VA hospitals in U.S. 
new - PSRS in coordination with NASA

MEDICATION ADMINISTRATION
MERS (Medication Error Reporting System)
MedMARx
MedWatch

TRANSFUSION MEDICINE
MERS-TM
SHOT (Serious Hazards of Transfusion) – U.K.

MEDICAL DEVICES
ECRI (International Medical Device Reporting System)
MAUDE (Manufacturer and User Device Experience) database

**VA PSRS (Patient Safety Reporting System)**
**mandatory at all VA hospitals in U.S. **
***new***** - PSRS in coordination with NASA**
**MEDICATION ADMINISTRATION**
**MERS (Medication Error Reporting System)**
**MedMARx**
**MedWatch**
**TRANSFUSION MEDICINE**
**MERS-TM**
**SHOT (Serious Hazards of Transfusion) – U.K.**
**MEDICAL DEVICES**
**ECRI (International Medical Device Reporting System)**
**MAUDE (Manufacturer and User Device Experience) database**

***INCIDENT REPORTS***

***LEARNING from PAST MISTAKES***

**Notes:**
MERS: U.S. Pharmacopoeia (private)
MedMARx: Pharmacopoeia

## 12-month period MedMARx data, 1999 (U.S. Pharmacopoeia, 2000)

6224 medication errors reported (only 3% resulted in patient harm)
Error types: omission, improper dose/quantity, unauthorized drug
Error causes: performance deficit , procedure not followed, knowledge deficit

Most reported contributing factor in all phases of medication          use (prescribing, documenting, dispensing, administering, monitoring): distractions

**6224 medication errors reported ****(only 3% resulted in patient harm)**
**Error types: omission, improper dose/quantity, unauthorized drug**
**Error causes: performance deficit , procedure not followed, knowledge deficit**
**Most reported contributing factor in all phases of medication          use ****(prescribing, documenting, dispensing, administering, monitoring)****: *****distractions***

***MEDICATION ADMINISTRATION***

***LEARNING from PAST MISTAKES***

**Notes:**
True causes may lie deeper and may be more complex.  Need to probe further than surface analysis of causes...

## Medical Event Reporting System for Transfusion Medicine (MERS-TM) 

FDA (Food and Drug Administration) published a final rule effective May 7, 2001, requiring hospitals and blood centers to maintain a method to report, investigate, and track errors and accidents.

**FDA (Food and Drug Administration) published a final rule effective May 7, 2001, requiring hospitals and blood centers to maintain a method to report, investigate, and track errors and accidents.**

***TRANSFUSION INCIDENT REPORTS***

***LEARNING from PAST MISTAKES***

## Serious Hazards of Transfusion (SHOT)
Started 1996
Confidential, voluntary submission of reports of deaths and major adverse events
Hospitals in U.K. and Ireland

Cumulative data for 1996-2000 (N=910)  (SHOT Annual Report, 1999/2000)

**Started 1996**
**Confidential, voluntary submission of reports of deaths and major adverse events**
**Hospitals in U.K. and Ireland**
**Cumulative data for 1996-2000 (N=910)  ****(SHOT Annual Report, 1999/2000)**

***TRANSFUSION INCIDENT REPORTS***

***LEARNING from PAST MISTAKES***

## TRANSFUSION
Compare data from reporting system (AIR) and direct observation (DO)  (Whitsett & Robichaux, 2001)
Component identification errors = 55% (DO) vs. 17% (AIR)

SURGERY
Interviews at 3 Boston teaching hospitals (Gawande, 2001)
70% of errors involved 2 or more clinicians
Areas for quality improvement
inexperience and supervision
communication (esp. at handoff) 
fatigue/workload

**Compare data from reporting system (AIR) and direct observation (DO)  ****(Whitsett & Robichaux, 2001)**
**Component identification errors = ****55% (DO) vs. 17% (AIR)**
**SURGERY**
**Interviews at 3 Boston teaching hospitals ****(Gawande, 2001)**
**70% of errors involved 2 or more clinicians**
**Areas for quality improvement**
**inexperience and supervision**
**communication (esp. at handoff) **
**fatigue/workload**

***FIELD STUDIES & SURVEYS***

***MONITORING CURRENT SYSTEM***

**Notes:**
Transfusion: 202 transfusions over 18 months at Emory U. hospital
DO reveals more about SOPs (deviations from and problems with) and don’t get reported (definition of error, no consequence)
AIR complements DO by adding info on non-observed phases (storage) and actual consequences of errors

## EMERGENCY DEPARTMENT
Average of 30.9 interruptions per 180 min study period
Average of 20.7 breaks-in-task in same study period
(Chisholm, Collison, Nelson, & Cordell, 2000) 

5.1 patients simultaneously under a physician’s care
37.5 min/hr spent managing 3 or more patients concurrently
Interruption every 12.6 minutes
(Hymel & Severyn, 1999) 

ANESTHESIA
Critical incident analysis: structured interviews
Human error involved in 68% of incidents reported
(Cooper, Newbower, & Kitz, 1984) 

OPERATING ROOM
Jumpseating in the operating room (Sexton, Marsch, Helmreich, Betzendoerfer, Kocher, & Scheidegger, 1998)

**Average of 30.9 interruptions per 180 min study period**
**Average of 20.7 breaks-in-task in same study period**
**(Chisholm, Collison, Nelson, & Cordell, 2000) **
**5.1 patients simultaneously under a physician’s care**
**37.5 min/hr spent managing 3 or more patients concurrently**
**Interruption every 12.6 minutes**
**(Hymel & Severyn, 1999)**** **
**ANESTHESIA**
**Critical incident analysis: structured interviews**
**Human error involved in 68% of incidents reported**
**(Cooper, Newbower, & Kitz, 1984)**** **
**OPERATING ROOM**
**Jumpseating in the operating room ****(Sexton, Marsch, Helmreich, Betzendoerfer, Kocher, & Scheidegger, 1998)**

***FIELD STUDIES & SURVEYS***

***MONITORING CURRENT SYSTEM***

**Notes:**
Although anesthesiologists make up only 5% of physicians in US, a is acknowledged as leading medical specialty in addressing issues of patient safety. (GABA 2000)
Critical incident technique adapted by Cooper from aviation
Analysis of closed malpractice claims
AIMS (Australia)
As in aviation, simulators have facilitated the exploration of SA

66% of errors in simulator were classified as human error (DeAnda & Gaba, 1990) 

At least 50% of all blood units, by estimate, are transfused by anesthesiologists (Krombach, Kampe, Gathof, Deifenbach, & Kasper, 2002)

## TRAINING: simulators

***INTERVENTIONS***

- Operating Room (Palo Alto, CA)

- Simulated Delivery Room (Palo Alto, CA)

- Operating Room, University of Basel, Switzerland

## TECHNOLOGY & REGULATION

***TECHNOLOGY & REGULATION***

***INTERVENTIONS***

- Source: Scottish National Blood Transfusion Service, ISBT 128

- Source: SurgiGuard

- Source: VA Hospitals,
- Bar Code Medication Administration

**Notes:**
Bar Code Medication Administration (BCMA) 
Medication bar codes on patients’ wristbands, IV tags, and medication 
packages, scanned by hand-held, wireless devices before meds given to patient
System was introduced into VA and has reduced medication errors
By 70% at relatively low cost (Gebhart, 1999).  This approach was
Adopted by how AVIS checked in returned rental cars

## STRATEGIES TO REDUCE ERRORS

**Proactive vs. reactive approach**
**Active involvement by all involved (management ****→ ****operators)**
**Develop and promote philosophy**
**invite communication**
**safety #1 priority**
**share findings and results**
**Set ambitious targets for error reduction initiative **
**Develop tracking mechanisms to expose errors and “near misses”**
**Thoroughly investigate errors, including a root cause analysis**
**Employ a systems approach**
**Allocate adequate resources**
**Ensure competence = every professional’s highest responsibility**
**Understand before you fix**
***Use results of Human Factors research***

## Hellenic Blood Transfusion Society

**2nd Panhellenic Congress  **
**April 2002**

## TRANSFUSION: case study

**Boston VA Medical Center**
**60 year old man with history of esophageal cancer.  Underwent a series of surgeries and follow-up procedures.  He was severely ill and the highest risk category patient.  During the last procedure he suffered a cardiac arrest.  In the process of reviewing the circumstances of his death it was discovered that he had received 2 units of packed red blood cells typed and cross matched for another patient.  Acute hemolytic reaction secondary to incompatible ABO transfusion was identified as the immediate cause of death.**
**Findings:**
**Each discipline (surgeon, anesthesia, nursing) identified comprehensive procedures for the identification of the patient prior to the procedure.  This is not, however, an integrated process.  Each utilizes procedures specific to their discipline.**
**A nurse assigned to assist did not participate in the patient id procedures; however he subsequently participated in the verification of blood prior to administration.  The omission of checking the patient’s ID (writs) band, by those participating in the verification was critical.  Members of the anesthesia who participated in the verification  also participated in the care of the patient who preceded this patient in OR #7 and had, by then, begun to confuse the two patients.  This was further precipitated by the storage of the previous patient’s blood in the refrigerator marked for OR #7 following completion of the case and his transfer to the recovery room.  The patient’s blood was later found to be stored and marked for OR #6.**
**Confirmation of patient identification as reflected on the ID (wrist) band was omitted during the verification process used for both units of blood.**