Reducing mishaps from medical management is central to efforts to improve quality and lower costs in health care. Nearly 100 000 patients are estimated to die preventable deaths annually in hospitals in the United States, with many more incurring injuries at an annual cost of $9 billion. Underreporting of adverse events is estimated to range from 50%-96% annually.1–3 This annual toll exceeds the combined number of deaths and injuries from motor and air crashes, suicides, falls, poisonings, and drownings.4 Many stakeholders in health care have begun to work together to resolve the moral, scientific, legal, and practical dilemmas of medical mishaps. To achieve this goal, an environment fostering a rich reporting culture must be created to capture accurate and detailed data about nuances of care.

Outcomes in complex work depend on the integration of individual, team, technical, and organisational factors. 5 6 A continuum of cascade effects exists from apparently trivial incidents to near misses and full blown adverse events. 7 8 Consequently, the same patterns of causes of failure and their relations precede both adverse events and near misses. Only the presence or absence of recovery mechanisms determines the actual outcome.9 The National Research Council defines a safety “incident” as an event that, under slightly different circumstances, could have been an accident.10 Focusing on data for near misses may add noticeably more value to quality improvement than a sole focus on adverse events.

Schemes for reporting near misses, “close calls,” or sentinel (“warning”) events have been institutionalised in aviation,w1 w2 nuclear power technology,w3 w4 petrochemical processing, steelw5 production,w6 military operations, and air transportation.w7-w11 In health care, efforts are now being made to create incident reporting systems for medical near misses 8 11–15 to supplement the limited …

https://www.bmj.com/content/bmj/320/7237/759.full.pdf

Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems

This paper discusses four topics relating to safety culture, three theoretical and one practical. The first considers why it is that an unsafe culture is more likely to be involved in the causation of organizational rather than individual accidents. It is the pervasive nature of culture that makes it uniquely suitable for creating and sustaining the co-linear gaps in defences-in-depth through which an accident trajectory has to pass. The second topic relates to pathological adaptations, and discusses two examples: the Royal Navy of the mid-nineteenth century and the Chernobyl reactor complex. The third issue deals with recurrent accident patterns and considers the role of cultural drivers in creating typical accidents. The final topic is concerned with the practical question of whether a safety culture can be engineered. It is argued that a safe culture is an informed culture and this, in turn, depends upon creating an effective reporting culture that is underpinned by a just culture in which the line between acceptable and unacceptable behaviour is clearly drawn and understood.

Achieving a safe culture : theory and practice

http://hanawitt.com.br/wp-content/uploads/Artigo_pidgeon__oleary.pdf

Man-made disasters: Why technology and organizations (sometimes) fail.

High risk industries such as commercial aviation and the oil and gas industry have achieved exemplary safety performance. This paper reviews how they have managed to do that. The primary reasons are the positive attitudes towards safety and the operation of effective formal safety management systems. The safety culture provides an important explanation of why such organisations perform well. An evolutionary model of safety culture is provided in which there is a range of cultures from the pathological through the reactive to the calculative. Later, the proactive culture can evolve towards the generative organisation, an alternative description of the high reliability organisation. The current status of health care is reviewed, arguing that it has a much higher level of accidents and has a reactive culture, lagging behind both high risk industries studied in both attitude and systematic management of patient risks.

https://qualitysafety.bmj.com/content/qhc/12/suppl_1/i7.full.pdf

Applying the lessons of high risk industries to health care

This paper deals with four safety paradoxes: (1) Safety is defined and measured more by its absence than its presence. (2) Defences, barriers and safeguards not only protect a system, they can also cause its catastrophic breakdown. (3) Many organisations seek to limit the variability of human action, primarily to minimise error, but it is this same variability – in the form of timely adjustments to unexpected events – that maintains safety in a dynamic and changing world. (4) An unquestioning belief in the attainability of absolute safety can seriously impede the achievement of realisable safety goals, while a preoccupation with failure can lead to high reliability. Drawing extensively upon the study of high reliability organisations (HROs), the paper argues that a collective understanding of these paradoxes is essential for those organisations seeking to achieve an optimal safety culture. It concludes with a consideration of some practical implications.

Safety paradoxes and safety culture

SUBTITLE: TO BE SUCCESSFUL, A SYSTEM MUST BE BUILT ON THE KNOWLEDGE THAT VALID FEEDBACK ON HUMAN OR SYSTEM FAILURES IS FAR MORE IMPORTANT THAN THE ALLOCATION OF BLAME.

Confidential incident reporting systems create vital awareness of safety problems.

This study examined incidents reported to NASAs Aviation Safety Reporting System from a different perspective: rather than focusing on the factors contributing to or causing incidents, this study concentrated on who and what (subsystems and information) enabled the recovery from an anomaly. Incident reports describing altitude deviations were classified as to cockpit type (glass or traditional), flight phase, agent restoring safety, and cockpit subsystems providing specific information that helped restore safety. The data revealed and quantified the agents, information, and factors that 'saved the day'. The flight crews used many sources of information to detect the altitude deviations: altimeter, outside scene, altitude alert, kinesthesia, attitude and communications monitoring. In the glass cockpits the crews also used the map display and autothrottles to detect deviations from assigned altitudes. There was an interaction between the person detecting the anomaly (controller/flight crew) and the type of cockpit. Glass cockpit flight crews detect proportionally more deviations than their counterparts in traditional cockpits, while controllers tend to detect more deviations involving traditional cockpits. There was no effect of cockpit position (captain/first officer). A model that details the flow of altitude information between air traffic control, flight crews, and cockpit subsystems, was developed and validated. This model identifies strengths and weaknesses in the flow of altitude information within the current ground/air system.

https://ti.arc.nasa.gov/m/profile/adegani/who%20or%20what.pdf

Who or what saved the day? A comparison of traditional and glass cockpits

This study explored the use of cockpit traffic displays for aircraft separation in instrument conditions. This is a new concept termed EFR for electronic flight rules. Four groups of three general aviation, instrument-rated pilots flew cross-country flights in twin engine simulators in the Multi-Cockpit Facility at NASA Ames. They were required to maintain two miles horizontal and 500 feet vertical separation from all other aircraft. There were 24 different geometries, or traffic situations, repeated randomly for each of the four experimental conditions for each group. Of 1152 aircraft encounters 12.8% were in violation of separation minimums. Eighteen of these were closer than 400 ft vertically or 1.6 nm horizontally. The minimum separation of all aircraft pairs was 293 ft and .13 nm. The type and time of evasive maneuvers showed no effect when sensor noise was simulated in the displayed traffic information. When pilots were able to communicate and coordinate their maneuvers, the time to resolve the conflict was reduced. Subject groups varied significantly in: time of conflict resolution, frequency and type of maneuvers, control activity, reported amount of threat, confidence, and satisfaction they perceived, and appraisal of the efficacy of their communications. Language: en

Primary separation between three aircraft using traffic displays

This volume contains the contributions of the participants in the NASA Ames Research Center workshop on the traffic-alert and collision avoidance system (TCAS) implementation for aircraft with cathode ray tube (CRT) or flat panel displays. To take advantage of the display capability of the advanced-technology aircraft, NASA sponsored this workshop with the intent of bringing together industry personnel, pilots, and researchers so that pertinent issues in the area could be identified. During the 2-day workshop participants addressed a number of issues including: What is the optimum format for TCAS advisories. Where and how should maneuver advisories be presented to the crew. Should the maneuver advisories be presented on the primary flight display. Is it appropriate to have the autopilot perform the avoidance maneuver. Where and how should traffic information be presented to the crew. Should traffic information be combined with weather and navigation information. How much traffic should be shown and what ranges should be used. Contained in the document are the concepts and suggestions produced by the workshop participants.

/pdf/the-traffic-alert-and-collision-avoidance-system-tcas-in-the-1vuwmgscnc.pdf

The Traffic-Alert and Collision Avoidance System (TCAS) in the glass cockpit

A flight simulator study of pilots' use of the Traffic-alert and Collision Avoidance System is described. Three levels of information on the location of other air traffic were presented to different groups of airline pilots. The amount of informtion on the location of other traffic had little effect on pilots' performance of the maneuvers commanded by the collision avoidance system. Measured crew responses were similar with no presentation of traffic location, with limited information, and with continuous traffic information. No learning effects were observed, and differences in flight experience did not contribute to the performance difference found.

Sheryl L. Chappell

Papers

Confidential incident reporting systems create vital awareness of safety problems.

Who or what saved the day? A comparison of traditional and glass cockpits

Primary separation between three aircraft using traffic displays

The Traffic-Alert and Collision Avoidance System (TCAS) in the glass cockpit

Information transfer in pilots' use of a collision avoidance system