Error, Stress and Teamwork in Aviation and Medicine

Error, Stress and Teamwork in Aviation and Medicine PowerPoint PPT Presentation


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Outline. Aviation's approach to safety and errorCountermeasuresHuman factors training (CRM)Assessing operational safety (UT)Automation in aviationTransfer of these technologies to medicine. Why aviation?. IOM reportSafety is super-ordinate goalTeamwork is essentialRisk varies from low to highThreat

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Error, Stress and Teamwork in Aviation and Medicine

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1. Error, Stress and Teamwork in Aviation and Medicine Summit 2000 - Better Outcomes Through Medication Healthcare Collaboration 29 November, 2000 Dave Musson, MD The University of Texas Human Factors Research Project

2. Outline Aviation’s approach to safety and error Countermeasures Human factors training (CRM) Assessing operational safety (UT) Automation in aviation Transfer of these technologies to medicine

3. Why aviation? IOM report Safety is super-ordinate goal Teamwork is essential Risk varies from low to high Threat & error come from multiple sources

5. Safety in Aviation Safety department (commercial) Training, ASAP Base flight saftey (military) NASA ASRS FAA Safety regualtion Research

6. Aviation approach to error System approach to system error Organized development of error countermeasures Research and data collection on an ongoing basis in support of safety

7. Aviation countermeasures designed to enhance safety Crew Resource Management (CRM) Automation Proceduralization Standardized training checklists

9. Crew Resource Management Mandated by FAA Formal training in Leadership, Communication Information management Issues in CRM Resistance on the part of some pilots Failure of early programs Multiple generations of CRM - slow process

10. Line Operations Safety Audit (LOSA) Observation of actual line operations (4000 to date) Structured observation methods Trained observers (UT and airline) Non-jeopardy conditions Non-punitive approach

11. LOSA results - error frequencies

12. LOSA results - error outcomes

13. Automation in aviation Introduced to improve safety Has solved one set of problems Produced new types of errors largely unanticipated Other problems associated with automation cultural acceptance, individual preferences

14. National preferences for automation

15. Automation Large variations in national tendencies towards usage Individual preferences Usability and design concerns Boeing vs. Airbus Possibility of loss of flying skills

16. Transfer of error countermeasures from aviation to medicine: CRM in medicine Automation in medicine

17. CRM in medicine Currently considered for: OR, ER, Hospitals, clinics Research at UT Hermann Hospital NICU Kantonspittel Basel OR Incident and accident analysis

18. CRM in Medicine - areas of concern Transferability of human factors programs (CRM) between airlines - difficult between countries - very difficult into medicine - ? Domain specific requirements Must be supported by ongoing research Modification as indicated by research Not a simple process

19. Automation in medicine Management of medication information Patient and lab information management Delivery of anesthesia Critical care monitoring devices

20. Automation in medicine - potential areas of concern Data entry errors - the most common error we observe in aviation New set of skills required training, acceptance, transfer between systems Usability issues proprietary differences, standardization Unforseen errors… **

21. Summary points Aviation has had a long history of reducing error at the system level - gradual change Many improvements, but not without problems Human resource management (CRM) as a means of improving safety potential benefits but also problems Automation - error reduction, but with new errors The need for data collection to assess interventions*

22. The University of Texas Human Factors Research Project URL: www.psy.utexas.edu/psy/helmreich/nasaut.htm

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