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Applying lessons from NASA helps manage threats and errors in pediatric cardiac surgery
Date:4/28/2014

to "proficiency" or "judgment," were consequential in that they led to an unintended clinical state. Over 60% of consequential errors (~20% of all patient flights) led to cycles of additional error and unintended state i.e. progressive loss of safety margins. Such cycles were very significantly associated with harmful patient outcomes, such as brain injury, residual cardiovascular lesions, or death. Deaths were almost always preceded by error cycles.

"We conclude that the progressive degradation of safety margins that occurs in most aviation disasters, and I use Air France 447 as an example, has direct corollaries in medicine," states Dr. Hickey. He and his co-investigators suggest that error needs to be expected, better understood, and better managed, and that heightened levels of vigilance are essential for prompt error detection. They believe that optimizing communication and resource utilization during unexpected deviations from the planned clinical journey (using techniques similar to "Crew Resource Management" in commercial aviation training) will likely improve error rescue and have a positive impact on patient outcomes.


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Contact: Nicole Baritot
press@aats.org
978-299-4520
American Association for Thoracic Surgery
Source:Eurekalert  

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