PATIENT SAFETY
Aviation Tools to Improve Patient Safety Jacqueline Ross, PhD, RN, CPAN OVER THE YEARS health care providers have used aviation models in patient safety in an effort to improve outcomes. Both industries involve complex systems which involve peoples’ lives and where safety is the key outcome. Teamwork is essential within both industries to function efficiently, and this teamwork is imperative because stressful conditions can arise quickly. Any human error can result in serious harm to people. However, unlike the aviation industry the health care industry took longer to convert from the culture of blame. More recently, we started to learn more from the aviation industry by adapting to checklists and standardization. More work is needed. This column is dedicated to discussion of some of the tools and techniques borrowed and adapted from the aviation industry.
Crew Resource Management Crew resource management (CRM) was developed by NASA in 1979 to improve air safety and reduce fatal accidents related to human errors. At that time, airline accidents were attributed to problems with interpersonal communication, leadership, and decision making that occurred in the cockpit. CRM is a model of team training. Effective teams need to have the correct skills and knowledge, as well as understanding of the other team members’ responsibilities.1 CRM has been used by aviation members for years with mainly positive results. Essential elements in CRM include conflict resolution, briefings, and performance reviews. Conflict resolution occurs when other team members feel safety measures are not being addressed. Team members must know that challenging the action of one of the team members is not an act of sabotage Jacqueline Ross, PhD, RN, CPAN, is a Senior Clinical Analyst, Department of Patient Safety, TDC, Napa, CA. Conflicts of interest: None to report. Address correspondence to Jacqueline Ross, 17491 Merry Oaks Trail, Chargin Falls, OH 44023; e-mail address: [email protected]. Ó 2014 Published by Elsevier Inc. on behalf of American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2014.09.004
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or insubordination but instead acting with the best interest of the patient in mind.1 Briefings entail a short summary of proposed action with team members; then members repeating their understanding of the coming actions.1 Performance reviews monitor and verify the actions of each other, keeping the safety of the patient at the forefront.1 Within health care, communication errors remain a major problem, and these communication errors are a large component of the majority of sentinel events. Therefore, CRM is very helpful. Key concepts of CRM include roles, communication, global assessment, support, and resources. The two roles, leader and follower, are interchangeable. The leader steps back and manages the event, organizes the team, delegates responsibility, sets clear goals, and distributes work appropriately.1 The follower assumes assigned responsibilities, provides task and cognitive support, and feeds back event management data.1 The communication concept requires that team members use direct eye contact, introduce themselves to other team members, use urgency not panic, close the loop by giving feedback, use nonjudgmental words, and establish communication paths.1 The global assessment concept requires both a physical and a mental ‘‘step back’’ to allow for one to see the whole picture and deliver a verbal review of the situation (this provides clarity of ideas, avoids fixation errors, and generates possible new ideas).1 The support concept maintains that asking for assistance when needed is not a sign of weakness, that incremental help may be needed, and requires knowledge of when and whom to call, ie, when one calls for help, what type of help is needed—technical, advice, or hands-on?1 The resources concept requires preparation for needs, understanding of the infrastructure, knowledge of how the system works, and promotion of thinking ‘‘outside the box’’ among the team. Situation, background, assessment, and recommendation (SBAR) is a good example of CRM using the concept of communication. SBAR is a structured and standardized communication format.
Journal of PeriAnesthesia Nursing, Vol 29, No 6 (December), 2014: pp 508-510
509
PATIENT SAFETY
Use of a structured format such as SBAR is beneficial when reporting changes in patient condition between health care providers. It closes the loop and also establishes a communication path.
Simulation Training Simulation training is another borrowed tool from the aviation industry. Simulation substitutes real experiences with artificial experiences that copy aspects of reality in an interactive way.2 The aviation industry uses simulation routinely to train, rehearse, and certify pilots to handle various scenarios in take-offs, landings, and emergencies. In health care simulation, training has been applied in different settings. It has been used for health care providers to learn techniques, such as performing an arterial blood gas. Mistakes can be made until proficiency is obtained, and no patients are hurt or injured. Simulation training can also be used for team-training exercises. Using the simulator, the team would be able to be assessed on decision making, leadership skills, communication, and judgment. Can health care use simulators routinely like in aviation.2 If the use of simulators is to be used on a more routine basis, one recommendation is to focus on team-training exercises. The Institute of Medicine recommends that health care providers are able to work across the health care environment with other health care providers.2 The ability to routinely work on various situations related to teams would be beneficial in developing better communication and decision making. One of the key issues involved in these exercises is the debriefing that follows the exercises.3,4 Debriefings have their origins from the military. Soldiers returning from battle were brought back and asked to share their stories in an effort to destress them, as well as for the leadership to adapt on the battlefield.3 Within each simulator experience are facilitators who manage the simulator experience. For simulations, debriefings may have similar meanings for some. The debriefing should be done soon after the scenario is completed in a positive, nonthreatening confidential environment. Most of the time used in the debriefing session should be dedicated to discussion and analysis of the events that occurred
during the simulator experience. The facilitators want to encourage the participants to share their feelings of the events.4 The challenge for nurses with debriefings is many nurses are not familiar with this idea of joint debriefings and may need to have individual debriefings as well.
Black Boxes Within the aviation industry is the use of black boxes. In fact, airplanes contain two black boxes: the flight data recorder and cockpit voice recorder. Although statistically speaking, the number of airline accidents are low and the availability of these black boxes allows for analysis of what caused the accident. The information is reviewed by a team that would include the manufacturer of the airliner, a National Transportation Safety Board air safety investigator, a National Transportation Safety Board transportation-safety specialist. This process could take weeks to months. But the information provides details on the cause of the accident and improvements can be made. A surgeon in Canada has developed a black box that could be used in surgery. Unlike the black boxes used in aviation, the goal with these black boxes is to avoid accidents. Developed by Dr. Teodor Grantcharov, this device monitors surgeons in real time and can alert them if potential errors are about to occur. This is accomplished by an ‘‘error-analysis’’ software, which has the ability to identify if there is some variation in practice.5 The device includes a camera which is on the surgeon so the entire operation is captured like the surgeon’s suturing technique and other skills within the operative fields. A microphone is also present so communication among the rest of the operating room team can also be reviewed. One issue that may remain a barrier is whether the use of black box would be discoverable to a legal team for malpractice. The ability of the surgical teams to use the black boxes as teaching tools to avoid mistakes and improve patient care would be very valuable. Reflecting back to aviation industry where pilots routinely use simulators to train and recertify, the black boxes are not simulators, but they do provide the ability to recreate the previous surgery. Additionally, the surgeon would receive an alert to potential deviations and have the opportunity to review previous surgeries and make needed changes.5
510
JACQUELINE ROSS
As highlighted in this column health care has borrowed from the aviation industry some tools for patient safety. Both industries are complex in nature and strive for safety. Some of the tools have
been used in health care for some time, such as checklists, whereas other tools are not yet in use. The overall goal remains improved in patient safety.
References 1. Sundar E, Sundar S, Pawlowski J, et al. Crew resource management and team training. Anesthesiol Clin. 2007;25:283-300. 2. Aggarwal R, Mytton O, Derbrew M. Training and simulation for patient safety. Qual Saf Health Care. 2010;19(Suppl 2):i34-i43. 3. Fanning R, Gaba D. The role of debriefing in simulationbased learning. Simul Healthc. 2007;2:116-125.
4. Zigmont J, Kappas L, Sudikoff S. The 3D model of debriefing: Defusing, discovering and deepening. Semin Perinatol. 2011;35:52-58. 5. Verel D. Coming Soon to a Hospital Near You: A Black Box for Surgery? Business of Innovation in Healthcare. 2014. Available at: http://medcitynews.com/2014/08/coming-soonhospital-near-surgical-black-box/. Accessed September 2, 2014.
Aviation Tools to Improve Patient Safety Jacqueline Ross, PhD, RN, CPAN OVER THE YEARS health care providers have used aviation models in patient safety in an effort to improve outcomes. Both industries involve complex systems which involve peoples’ lives and where safety is the key outcome. Teamwork is essential within both industries to function efficiently, and this teamwork is imperative because stressful conditions can arise quickly. Any human error can result in serious harm to people. However, unlike the aviation industry the health care industry took longer to convert from the culture of blame. More recently, we started to learn more from the aviation industry by adapting to checklists and standardization. More work is needed. This column is dedicated to discussion of some of the tools and techniques borrowed and adapted from the aviation industry.
Crew Resource Management Crew resource management (CRM) was developed by NASA in 1979 to improve air safety and reduce fatal accidents related to human errors. At that time, airline accidents were attributed to problems with interpersonal communication, leadership, and decision making that occurred in the cockpit. CRM is a model of team training. Effective teams need to have the correct skills and knowledge, as well as understanding of the other team members’ responsibilities.1 CRM has been used by aviation members for years with mainly positive results. Essential elements in CRM include conflict resolution, briefings, and performance reviews. Conflict resolution occurs when other team members feel safety measures are not being addressed. Team members must know that challenging the action of one of the team members is not an act of sabotage Jacqueline Ross, PhD, RN, CPAN, is a Senior Clinical Analyst, Department of Patient Safety, TDC, Napa, CA. Conflicts of interest: None to report. Address correspondence to Jacqueline Ross, 17491 Merry Oaks Trail, Chargin Falls, OH 44023; e-mail address: [email protected]. Ó 2014 Published by Elsevier Inc. on behalf of American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2014.09.004
508
or insubordination but instead acting with the best interest of the patient in mind.1 Briefings entail a short summary of proposed action with team members; then members repeating their understanding of the coming actions.1 Performance reviews monitor and verify the actions of each other, keeping the safety of the patient at the forefront.1 Within health care, communication errors remain a major problem, and these communication errors are a large component of the majority of sentinel events. Therefore, CRM is very helpful. Key concepts of CRM include roles, communication, global assessment, support, and resources. The two roles, leader and follower, are interchangeable. The leader steps back and manages the event, organizes the team, delegates responsibility, sets clear goals, and distributes work appropriately.1 The follower assumes assigned responsibilities, provides task and cognitive support, and feeds back event management data.1 The communication concept requires that team members use direct eye contact, introduce themselves to other team members, use urgency not panic, close the loop by giving feedback, use nonjudgmental words, and establish communication paths.1 The global assessment concept requires both a physical and a mental ‘‘step back’’ to allow for one to see the whole picture and deliver a verbal review of the situation (this provides clarity of ideas, avoids fixation errors, and generates possible new ideas).1 The support concept maintains that asking for assistance when needed is not a sign of weakness, that incremental help may be needed, and requires knowledge of when and whom to call, ie, when one calls for help, what type of help is needed—technical, advice, or hands-on?1 The resources concept requires preparation for needs, understanding of the infrastructure, knowledge of how the system works, and promotion of thinking ‘‘outside the box’’ among the team. Situation, background, assessment, and recommendation (SBAR) is a good example of CRM using the concept of communication. SBAR is a structured and standardized communication format.
Journal of PeriAnesthesia Nursing, Vol 29, No 6 (December), 2014: pp 508-510
509
PATIENT SAFETY
Use of a structured format such as SBAR is beneficial when reporting changes in patient condition between health care providers. It closes the loop and also establishes a communication path.
Simulation Training Simulation training is another borrowed tool from the aviation industry. Simulation substitutes real experiences with artificial experiences that copy aspects of reality in an interactive way.2 The aviation industry uses simulation routinely to train, rehearse, and certify pilots to handle various scenarios in take-offs, landings, and emergencies. In health care simulation, training has been applied in different settings. It has been used for health care providers to learn techniques, such as performing an arterial blood gas. Mistakes can be made until proficiency is obtained, and no patients are hurt or injured. Simulation training can also be used for team-training exercises. Using the simulator, the team would be able to be assessed on decision making, leadership skills, communication, and judgment. Can health care use simulators routinely like in aviation.2 If the use of simulators is to be used on a more routine basis, one recommendation is to focus on team-training exercises. The Institute of Medicine recommends that health care providers are able to work across the health care environment with other health care providers.2 The ability to routinely work on various situations related to teams would be beneficial in developing better communication and decision making. One of the key issues involved in these exercises is the debriefing that follows the exercises.3,4 Debriefings have their origins from the military. Soldiers returning from battle were brought back and asked to share their stories in an effort to destress them, as well as for the leadership to adapt on the battlefield.3 Within each simulator experience are facilitators who manage the simulator experience. For simulations, debriefings may have similar meanings for some. The debriefing should be done soon after the scenario is completed in a positive, nonthreatening confidential environment. Most of the time used in the debriefing session should be dedicated to discussion and analysis of the events that occurred
during the simulator experience. The facilitators want to encourage the participants to share their feelings of the events.4 The challenge for nurses with debriefings is many nurses are not familiar with this idea of joint debriefings and may need to have individual debriefings as well.
Black Boxes Within the aviation industry is the use of black boxes. In fact, airplanes contain two black boxes: the flight data recorder and cockpit voice recorder. Although statistically speaking, the number of airline accidents are low and the availability of these black boxes allows for analysis of what caused the accident. The information is reviewed by a team that would include the manufacturer of the airliner, a National Transportation Safety Board air safety investigator, a National Transportation Safety Board transportation-safety specialist. This process could take weeks to months. But the information provides details on the cause of the accident and improvements can be made. A surgeon in Canada has developed a black box that could be used in surgery. Unlike the black boxes used in aviation, the goal with these black boxes is to avoid accidents. Developed by Dr. Teodor Grantcharov, this device monitors surgeons in real time and can alert them if potential errors are about to occur. This is accomplished by an ‘‘error-analysis’’ software, which has the ability to identify if there is some variation in practice.5 The device includes a camera which is on the surgeon so the entire operation is captured like the surgeon’s suturing technique and other skills within the operative fields. A microphone is also present so communication among the rest of the operating room team can also be reviewed. One issue that may remain a barrier is whether the use of black box would be discoverable to a legal team for malpractice. The ability of the surgical teams to use the black boxes as teaching tools to avoid mistakes and improve patient care would be very valuable. Reflecting back to aviation industry where pilots routinely use simulators to train and recertify, the black boxes are not simulators, but they do provide the ability to recreate the previous surgery. Additionally, the surgeon would receive an alert to potential deviations and have the opportunity to review previous surgeries and make needed changes.5
510
JACQUELINE ROSS
As highlighted in this column health care has borrowed from the aviation industry some tools for patient safety. Both industries are complex in nature and strive for safety. Some of the tools have
been used in health care for some time, such as checklists, whereas other tools are not yet in use. The overall goal remains improved in patient safety.
References 1. Sundar E, Sundar S, Pawlowski J, et al. Crew resource management and team training. Anesthesiol Clin. 2007;25:283-300. 2. Aggarwal R, Mytton O, Derbrew M. Training and simulation for patient safety. Qual Saf Health Care. 2010;19(Suppl 2):i34-i43. 3. Fanning R, Gaba D. The role of debriefing in simulationbased learning. Simul Healthc. 2007;2:116-125.
4. Zigmont J, Kappas L, Sudikoff S. The 3D model of debriefing: Defusing, discovering and deepening. Semin Perinatol. 2011;35:52-58. 5. Verel D. Coming Soon to a Hospital Near You: A Black Box for Surgery? Business of Innovation in Healthcare. 2014. Available at: http://medcitynews.com/2014/08/coming-soonhospital-near-surgical-black-box/. Accessed September 2, 2014.
