Journal of Surgical Simulation 2019; 6: A: 1 - 1
Published: 06 November 2019
Special Issue: Think like a pilot - transferring error management to healthcare
Ever made a mistake? Human error is inevitable in all walks of life. It occurs regardless of your level of experience and regardless of how diligent you are. It generally has little effect, unless you work in a “safety critical” industry. Aviation and healthcare are two such industries although they have very different approaches to managing error. They also have very different outcomes regarding mortality/morbidity related to error. We will analyse how aviation achieves these results and how they could be transferred to healthcare.
Aviation has a three-stage approach to managing error. Firstly, we have a “Just Culture” which means we can own up to genuine mistakes without fear of disciplinary action or sanctions as long as we co-operate with investigating how the error occurred. It is not a “No-Blame” culture - we are still expected to take responsibility for our actions. We are entrusted with extremely expensive equipment and the safety of hundreds of people in a very competitive industry with tight profit margins. “Just Culture” does not mean a laissez-faire approach and does not excuse gross negligence or deliberate error. Secondly, we investigate each event to find why the error occurred. We usually identify a ‘tripwire’ which led to the individual making the error. We assess whether we can re-engineer the system to remove the tripwire and, if possible, add a ‘safety-net’ to reduce the chance of recurrence. Thirdly, we train staff in error management as part of both initial training and also recurrent training. Aviation globally is now focussing on introducing Evidence-Based Training (EBT) to better meet the needs of crew and make most effective use of expensive training time. Incidents are recorded and categorised to decide what issues are causing accidents/incidents worldwide and which need addressed both in simulation training and during line-training. The severity and regularity determine how often they need to be included in training - always, in alternate modules or as part of a three-year cycle.
These principles are relevant and transferable to healthcare and could potentially be equally successful. Success however relies on a change in culture by both staff and patients. Error needs to accepted as inevitable in healthcare, as it is in aviation and that the outcome is determined by how it is managed. We need to focus on “What went wrong” as opposed to “Who went wrong” and accept that attributing blame and demanding retribution is not a sustainable approach. Our staff deserve better than that. This presentation aims to enable staff to return to their units thinking like pilots and hopefully replicating the results enjoyed by aviation over the last forty years.
error management; healthcare; evidence-based training; human factors; aviation
This presentation was given at the 8th Annual Homerton Simulation Conference, Homerton University Hospital, London, UK, on 6 December 2018.
Please also see Niall Downey's invited Editorial in association with this presentation, Journal of Surgical Simulation (2019) 6, 27–30 DOI: https://doi.org/10.1102/2051-7726.2019.0005
Conflict of interest: Niall Downey is Managing Director of Frameworkhealth Ltd, a company that provides aviation-style error management
training to the health service.