Reduction of Adverse Events.

What Health Care is Learning From the Aviation Industry

<div class="htmlview paragraph">The role of Cockpit Resource Management (CRM) in enhancing flight safety is being increasingly recognized throughout the aviation industry. At the same time, pilot Professional Standards Committees (PSC) are also being acknowledged as having a definite place, along with Cockpit Resource Management, in aircraft accident prevention. This paper examines the similarities and differences between CRM and PSC as well as their relationship to each other in positively affecting flight safety.</div> <div class="htmlview paragraph">CRM is generally defined as a flight crew-coordinated team effort that uses all means available to enhance safe flight crew operations. Resources here includes all elements, both in and out of the cockpit, that reinforce the crew's ability to function as a team while they cope with various real-life situations. Management skills include the ability to lead and to follow, to effectively communicate within the cockpit and outside it, to gather and evaluate information, to assess and assign crew member task loads. It also includes the ability to make decisions, to resolve conflicts and to control stress.</div> <div class="htmlview paragraph">All elements of CRM training should reinforce cockpit chain-of-command and the crew's situational awareness of what is going on throughout the operation of the flight. Lack of leadership, followership, i.e. teamwork, and loss of situational awareness have probably been cited more in the majority of today's human performance related accidents than any other causes.</div> <div class="htmlview paragraph">With its emphasis on behavioral modification to enhance crew performance, CRM has certainly had some real success stories. The highly publicized 1989 United Airlines' accidents, near Honolulu, Hawaii and at Sioux City, Iowa, are two prime examples of crew teamwork at its absolute best under extremely trying conditions. At Hawaii, the B-747 crew had to make a two-engine-out night landing with a substantial portion of the right forward fuselage missing. And, at Sioux City, the DC-10 crew had to instantly invent a flying technique to contend with a critically wounded aircraft that had almost no flight control ability following the catastrophic failure of the center engine.</div> <div class="htmlview paragraph">Both crews credited their CRM training with having helped them to cope with these unprecedented situations that “no one ever dreamed would happen.”</div> <div class="htmlview paragraph">CRM is basically an extension of each airline management's operating philosophy. It emanates from the top down and reflects the corporate culture and management's commitment to the program. As a result, the quality of the programs and training courses vary widely at present. They range from mere lip service at one company to another corporation's total dedication to CRM. All CRM programs require some commitment of airline resources.</div> <div class="htmlview paragraph">CRM programs also require FAA scrutiny and approval. They are designed to further flight safety and to produce a more efficient cockpit operating atmosphere. “Using all available resources” is a basic premise of Cockpit Resource Management programs and involves all the crew, the aircraft and the flight environment. CRM programs are designed to enhance the Captain's authority by providing the best combination of available resources to assist in the command decision requirement of the FAR's that still holds the captain responsible for the safety of the flight.</div>

Surgery in Safe Hands

Self-reported Medication Adherence and Adverse Patient Safety Events in CKD

The profile of human factors has increased in prominence in medical education over the last decade. Adapted from the aviation industry’s ‘Crew Resource Management’, it is defined as ‘systems, behaviours or actions that modify human performance’, with the aim of improving patient safety. In many courses, such as Intermediate/ Advanced Life Support (ILS/ALS), there is now a chapter dedicated to human factors in the course handbook. ‘Human Factors in the Healthcare Setting’ is a course book from the Advanced Life Support Group (ALSG). In terms of size, it sits between the small pamphlets and online resources found on the NHS Patient Safety First website and heavier, more academic tomes such as Flin’s ‘Safety at the Sharp End: A Guide to Non-Technical Skills(1) or Decker’s ‘Patient Safety: A Human Factors Approach(2). The book covers the major human factors topics in small chapters, each about ten pages long. The chapters start with some background models that would be familiar to those who have had formal management teaching: Reason’s Swiss cheese model of accident causation and the Myers-Briggs Type Indicator for personality. The second part of the chapter then deals with practical strategy and application. Some strategies will be familiar to those already working in the NHS such as the SBAR for conducting medical handovers. Others have been adapted from the aviation industry (e.g. T-DODAR used by British Airways pilots to aid decision-making) or locally-developed aids which have not yet achieved wide-spread use (e.g. STARR from the Lancashire Simulation Centre). The book concludes with four clinical scenarios across a wide variety of settings (although not a primary care scenario), some of which will

Research has shown that lack of non-technical skills (also called, Crew Resource Management – CRM) contributes to most personal and process safety incidents in high-risk industries. Situational awareness in the most influential non-technical skill. Authors developed a disruptive program to generate situational awareness competencies and improve non-technical skills of front-line employees. The program is called: Permanent Attention. It combines best practices adapted from high-risk industries and industrial psychology science to generate statistically significant improvements in situational awareness competencies through a sustainable approach. The paper shows real case applications from two organizations where the Permanent Attention program has generated significant improvement in the participants’ situational awareness competency and non-technical skills (CRM) acquisition and retention. The program is executed with the learner at the centre of the process. The Situation Awareness Global Assessment Technique (SAGAT, Endsley, and Garland, 2000) is used to measure the levels of situational awareness competency before and after the training, to determine the impact achieved through the program. The ‘Repeated measures – ANOVA’ statistic model is used to scientifically demonstrate the significant impact of the process in the three elements of situational awareness: Attention, Comprehension and Anticipation. The training sessions in-between SAGATs contain theoretical information and practical exercises that equip the participant(s) with fundamentals. Exercises for each element of the situational awareness have been designed to obtain optimal skills. To complement the practice of non-technical skills, employees are exposed to simulations of critical operational situations, so they can demonstrate their leadership, communications, teamwork, decision-making skills in group and learn how to manage stress in such situations. The levels of situational awareness competencies are periodically monitored via practical field-based SAGAT exercises after the training, to ensure a sustained improvement in the participants’ competencies. The feedback provided immediately after each SAGAT is key to let the participant focus on the element(s) of situational awareness that require improvement. Once the feedback is received, the participant is requested to self-evaluate her level on each element of situational awareness. This reinforces self-consciousness and encourages a sense of commitment to improve by conviction, not by imposition. This novel methodology gives the organization a clear metric on the return on the investment the program offers and allows very specific interventions to improve individual and group level non-technical skills across the organization. A truly disruptive method. The paper shows how the Permanent Attention instructional design combines Endsley's research from the aviation and nuclear industries, with Knowles’ andragogy (2015) theory to achieve competency acquisition and retention. Novel approaches such as the SAGAT, are used with scenarios that are familiar to the target population. Participants’ levels of situational awareness competency are measured before and after the training to determine whether a statistically significant impact was achieved through the program. Permanent Attention has been implemented in organizations with a wide range of maturity. Case-studies are presented to illustrate the process, results, and limitations in two leading drilling companies, in which 60 to 70% of incidents had situational awareness as a contributing factor, over last five years. The implementation of the program has brought statistically significant improvements in the competency of employees and the pilot in Colombia has shown early signs of accident reduction.

Systematic development of a patient safety culture is necessary because lack of quality care leads to human suffering. The aim of this review was to identify evidence of obstetric adverse events (AEs) and near-misses in the context of patient safety. We conducted a search of the published literature from Europe, Australia and the USA in the following databases: Cinahl, Cochrane, Maternity and Infant Care, Ovid, Pro-quest and PubMed, guided by PRISMA procedures. A total of 427 studies were screened, 15 full papers retrieved and nine studies included in the final thematic analysis. The selected papers address a broad spectrum of adverse patient safety events in obstetric care. The themes that emerged were: type of AEs, near-misses and their consequences, strategies to support and improve Patient Safety (PS) and domains related to the WHO Patient Safety competence outcomes. The findings of the first theme were grouped into the following categories: healthcare professionals’ perspectives on ethical conflicts, attributing blame and responsibility, and patients’ perspectives on lack of trust and involvement, as well as medication errors. The second theme, strategies to support interventions to improve PS, was based on two sub-themes: communicating effectively and gaining competence by learning from adverse events, while the third theme was domains related to the WHO Patient Safety competence outcomes. In conclusion, few studies have examined strategies for managing AEs despite the existence of programmes that target the implementation of changes, such as improved teamwork training. In addition to exploring strategies to make safety a priority for patients and healthcare professionals, it is of the utmost importance to improve communication with patients and between professionals in order to maintain and enhance safety. Efforts by organizations and individuals to continuously develop knowledge about the risk of AEs and the use of best practice guidelines are also essential.

Training teams and leaders to reduce resuscitation errors and improve patient outcome

Teaching Aviation Crew Resource Management in a Pharmacy Curriculum

Crises in the operating room, often resulting from human factors, endangers patient safety. Simulation-based training to develop non-technical skills shows promise in managing these crises. This review examines the simulation techniques, targeted healthcare professionals, non-technical skills, crisis scenarios, and evaluation metrics used in operating room crisis management training. Systematic review. MEDLINE, APA PsycInfo and Web of Science databases were searched for peer-reviewed articles published between January 2004 and March 2024. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review protocol has been registered on the Open Science Framework (OSF) (https://osf.io/7bsc8). The inclusion criteria were as follows: (1) The study population comprised healthcare and medical professionals or students; (2) the intervention involved a simulated learning or training experience; (3) the outcomes focused on non-technical skills or crew resource management; (4) the training setting was the operating room (simulated or real); and (5) the learning scenarios depicted a crisis or an adverse event. This systematic review identified 29 eligible articles. The findings highlight the predominance of high-fidelity simulations, primarily targeting medical staff rather than nurses or other healthcare professionals. Training focused on communication, teamwork, situation awareness, problem solving, and decision making, with scenarios mostly addressing patient deterioration. Assessments reached up to Kirkpatrick's Level 3, demonstrating a positive training impact through learners' reactions and learning metrics rather than behavior and organizational results. Despite their effectiveness, current training practices exhibit limitations. Incorporating nurses and other paramedical staff in interprofessional training, as well as emphasizing team-related scenarios and evaluating behavioral changes in practice, could enhance training effectiveness. This has implications for interprofessional healthcare education and skills transfer to real-world settings, ultimately improving patient safety.

A Canadian consensus definition of near-miss events in liver surgery for the real-time quality benchmarking of laparoscopic liver surgery

Reporting near-miss events in nursing homes

WOCRM is based on the Crew Resource Management (CRM) training program developed in the aviation industry in the 1980's. It is an attitudinal and behavioural training methodology; used to continuously engage the crews in repetitive, hands on and interactive exercises and simulations, providing structured feedback to develop each crew members’ non-technical skills. The training was first developed for airline cockpit crews in the 1980's and has since flourished within commercial and military aviation, mining and medical industries. A review done for Qantas by David Hainsworth, (Briefing to Qantas safety management, 2000) indicated that 96% of their LTI's root causes were behavioural in nature. According to Edkins (2002), it follows that if we agree that the focus of CRM is to modify and reinforce effective safety Behaviour, it is reasonable then to assume that LTI's will be reduced. If LTI's are reduced, so too then is the costs associated with them, which in Oil and Gas can go into the billions and so a very good Return on Investment (ROI). Focusing on Oil and Gas, the IOGP reports clearly indicate that Well Operations Crew Resource Management (WOCRM) training is required and that it should be incorporated into the mandatory International Well Control Forum (IWCF) and International Association of Drilling Contractors (IADC) Well Control Training. This is all well and good, however, if anything is to be learned from Dr Graham Edkins, (The state of the nation: How mature are HF/NTS programs within the Australian Airline Industry?, 2012) training alone is not enough. From a psychological standpoint, to change or correct a Behaviour takes 66-270 days of repetition and constructive feedback. Therefore, the new Behaviour, process or procedure must be repeated for at least 3 months, to ensure that the Behaviour or procedure will in fact be applied when needed, especially in a stressful situation. This then implies the need to add coaching techniques to the methodology, which this paper will introduce. The major benefit to Oil and Gas, is that all of the techniques mentioned herein have already been created and developed, and our Industry simply has to apply the lessons learned from those that are more advanced, to create a continuous personal development methodology to reduce Lost Time Incidents (LTI's) caused by human error, which would have a potentially massive effect on the financial loss associated with these errors, concluding that this methodology could have a very impressive Return on Investment (ROI) for companies large and small.

Millions of children in the United States have been infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), with many infections leading to hospitalization. For pediatric patients, especially younger children, treatment options are limited. Remdesivir has demonstrated a positive safety and efficacy profile in adults, but little data is published regarding remdesivir use in pediatric patients. Additional data for SARS-CoV-2 treatments in pediatric patients is required to prevent further SARS-CoV-2-related morbidity and mortality. At a single pediatric academic medical center, the safety and efficacy of remdesivir was evaluated. A retrospective review of patients admitted to a pediatric academic medical center who received remdesivir over a 17-month period was completed. All pediatric patients who received at least 1 dose of remdesivir were included. Safety and efficacy were assessed using national organization's definitions of clinical improvement, bradycardia, hypertension, acute kidney injury and drug-induced liver injury. There were 48 pediatric patients included in this study with 29% of patients admitted to the pediatric intensive care unit. Less than one-third of patients received the full treatment course of remdesivir, with over half of patients not completing therapy due to symptomatic improvement or hospital discharge. Majority of patients required some level of supplemental oxygen support. The median World Health Organization score was consistent throughout all 5 days of therapy. No patients experienced significant bradycardia, hypertension, acute kidney injury, or drug-induced liver injury. Remdesivir may correlate with clinical stability or improvement and demonstrates safety when used in pediatric patients. A randomized controlled trial is needed to confirm these findings.

The fast-paced and multifaceted nature of patient care in the emergency department makes our discipline especially prone to errors and adverse events. In recent years, strategies such as formal communication and medical team training have been proposed as potential means to enhance patient safety. In many ways, practice dynamics particular to the emergency department make this setting almost ideal for implementation of these strategies. This article reviews concepts of communication and team training in medicine, including those learned from the aviation industry (known as crew resource management). Recent literature pertaining to teams and communication in medicine is reviewed.