May 2001
Volume 65 |
Number 5
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RESIDENTS' REVIEW
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| Developing
a Culture of Safety
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Jason T. Vigue, M.D.
Alternate Delegate to AMA Resident and Fellow Section
Many issues were covered at the American Medical Association
(AMA) Resident/Fellow Section (RFS) Interim Meeting in Orlando,
Florida, last December. One topic included a discussion on safety
in medicine, moderated by keynote speaker, John Nance. Mr. Nance
an airline pilot, attorney and national safety expert has been
called upon to help medicine apply the safety processes that have
transformed aviation. He is also a board member of the National
Patient Safety Foundation.
Mr. Nance believes physicians and other health care providers
can learn from aviation because both industries have similar characteristics.
A comparison of the practice of anesthesiology and aviation proves
how similar they are.
Both anesthesiologists and pilots are carefully selected, highly
trained professionals who are to maintain high standards, both
internally and externally imposed, while performing difficult
tasks in life-threatening environments. Both groups use highly
technical equipment and function as key members of a team of specialists
forced to operate under conditions that at times are far from
ideal. 1 In addition, both fields
involve extremely complex systems of which the human element is
a major component. The perceived crisis concerning safety and
errors, which is gaining increasing attention in health care,
is not dissimilar to that experienced by the aviation industry
in the 1970s. Recognition of these commonalities can help health
care providers understand the connection between principles of
safety within the two industries and to adapt aviation safety
lessons for medicine. 2
The majority of accidents in anesthesia probably arise from human
error. Several studies have shown that 75 percent of intraoperative
cardiac arrests appear to have been caused by preventable anesthetic
errors, while inadequate vigilance contributed to one-third of
deaths in another study. 3 These statistics
are similar to those in aviation, where three-quarters of all
air carrier accidents are attributed to operator mistakes. Nance
stated that physicians and pilots can develop a type of command
stress that comes from feeling they have to maintain complete
control of a situation, manage everything that happens and never
make a mistake. He said the airline industry found that this isolated
pilots and that they tended to ignore important roles support
staff could play. Most anesthesiologists also work in a team setting,
either with a nurse anesthetist, hospital staff or other physicians,
but that does not mean they feel any less isolated than pilots.
Mr. Nance shared some of the key ideas and learned lessons that
transformed the aviation industry from one in crisis to one that
today maintains an excellent safety record. He offered much advice:
Safety begins with two-way communication. Create an atmosphere
of communication and teamwork by training professionals of all
levels to interact, be assertive, be a part of the team and take
individual responsibility for safety.
Complex systems fail in complex ways. There is not a probable
cause to an incident: There are multiple causes. Incident investigations
that focus only on who erred often fail. Root-cause analyses that
investigate why the problem occurred and what factors caused the
failure will help improve the system.
Blame and punishment are conducive to silence and are useless
for the prevention of future errors.
Persistence is key. The above items involve a paradigm shift
that takes time. Change in safety culture requires leadership,
teamwork and dedication to a common goal: safer systems. 4
Although the current practice of anesthesia is thought to be
safe, the profession rightly seeks continued improvement in quality
and safety. Human error will continue to be the primary cause
of accidents. There remains a need to continue research into the
causes of human error and decision-making. Resident physicians
and nurse anesthetists need to be trained in human factors and
team management in a manner similar to the aviation industry.
There also exists a need to track and study near-misses in anesthesia,
while working independently of any medicolegal process. I will
end with this bit of enlightenment:
The greatest mistake you can make in life is to
be continually fearing you will make one.
----Elbert Hubbard. The Note Book, 1927.
References
1. Allnut MF. Human factors in accidents. Brit
J Anaesth. 1987; 59(7):856-864.
2. Noble J. Overcoming barriers to examining
errors. Risk Management Foundation of the Harvard Medical Institutions-Resource
Web site. ; 1999.
3. Green R. The psychology of human error. Eur
J Anaesthesiol. 1999; 16(3):148-155.
4. Executive summary-national patient safety
foundation. American Medical Association Web site www.ama-assn.org/med-sci/npsf/wisc.htm;
1999.
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Jason
T. Vigue, M.D., is a CA-1 resident in anesthesiology, University
of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
He is also an instrument-rated private pilot. |
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