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Welcome to the Patient Safety Initiative

As an FAA certificated Airline Transport  Pilot (ATP) with thousands of hours as “PIC” (pilot in command) and a triple board certified surgeon who practices and teaches in a large academic medical center, I have always been an enthusiastic advocate of comparing pilot training and surgical training.  As such, I teach and live the message that the aviation safety model is one that can be used to reduce risks that patients face during surgical care.  I was an early adopter of processes such as pre-procedure time outs and checklists that have now become much more commonplace.

So I am someone who spends of a lot of time thinking about patient safety.  It is my view that the “High Reliability Organization” (HRO) safety theory used in the aviation industry (and other high risk industries) has the potential to save many lives and reduce errors in patient care.  High Reliability Organizations are defined as high risk, error-intolerant systems that repeatedly carry out potentially dangerous procedures with minimal actual error and HRO safety methods have been developed based largely on aviation accident studies.  HROs manage risks by being completely consumed with understanding and anticipating all possible chances for errors and effectively trapping small missteps before major adverse events have a chance of taking place.  The critical importance of this concept of error trapping and recoveryfrom minor adverse events has been demonstrated in numerous HRO safety models.  But, until recently (and even now, only minimally) has never been applied to the healthcare setting.

High reliability safety theory defines a number of individual and organizational features that have successfully reduced the risk of adverse outcomes in complex systems.  Safety, error avoidance and error mitigation in HROs are maintained with important sets of skills that can also be used for safety in surgery.    These safety skills are broadly grouped into six categories: Crew Resource Management (CRM), Situational Awareness (SA), time critical decision making, team leadership and supervision, precision communication skills, and Human Factors (HF).  These skills are closely inter-related and incorporate the central principles of team-work, individual performance and precision of communication.  Published data supports the concept that safety models from these systems can be utilized to enhance and improve safer surgical outcomes.

The sum total of this aviation style safety training blended with surgical safety is a “high reliability mindset” that is herein advocated and incorporates the error awareness theories of HROs with error avoidance strategies involving personal and team behaviors.  This type of training can be added to the current surgical trainee curriculum as well as to surgical practice to avoid errors and unintended outcomes in surgery.  The reason a “high reliability mindset” must be adopted for safe surgical training and practice is highlighted by an important difference between safety designs in healthcare and HROs.  HRO systems are engineered with the expectation that individuals can and will make mistakes and that the system itself must be engineered to catch these mistakes.   In healthcare systems, physicians and nurses have been granted a loftier status. We are expected not to make mistakes despite operating under equally stressful conditions in a system that is not attuned to catching small missteps. The system as it exists in healthcare is not programmed to efficiently trap small error which leaves physicians and nurses in an environment demanding perfection without the system safety mechanisms built into HROs.  For this reason it is important to sustain a mindset that makes awareness and avoidance of the potential for errors part of daily surgical care.  Safe outcomes depend upon managing those risks aggressively and continually detectingand intervening in small errors before they are allowed to produce adverse outcomes.

This blog will be dedicated to exploring the High Reliability Mindset as it applies to healthcare as well as other relevant and pertinent patient safety issues.  Subsequent postings will examine how each of the skills of HROs can be used in healthcare to minimize the chances of inadvertent harm coming to patients during their care for serious illnesses.

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Posted in High Reliability Organizations, Patient Safety.

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4 Responses

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  1. Kris Tremblay says

    Very interesting! Look forward to learning more about this. Anything to assist us in the prevention of human error is a wonderful idea!

  2. Ian Stahl says

    I think this will definitely be a big step forward for medicine. Great job!

  3. Sue Brien says

    Sutcliffe and others have referred to this state as “mindfulness”.
    Can mindfullness be taught, mentored, and assessed?
    Is it a critical yet unnamed part of professionalism?
    Looking forward to your discussion.

  4. Douglas Dotan says

    Dr. Sthal, your reference to adopting a “high reliability mindset” needs not to be only for safe surgical training and practice but in all processes in the healthcare setting. You make the observation of the important difference between safety designs in healthcare and HROs. Yes, HRO systems are engineered with the expectation that individuals can and will make mistakes and that these systems are engineered to catch these mistakes. In healthcare physicians and nurses are expected not to make mistakes, therefore the ‘mindset’ is not readilly receptive to the CRM approach. The small missteps, or problems that your refer to, are encountered every day by everyone. Because the processes in the ‘systems’ as they exist are not programmed to efficiently disclose issues and areas of concern, and we do not encourage a desire to continually improve, phycians and nurses continue to work in an environment without a system safety mechanism. I agree, safe outcomes depend upon awaren!
    ess, and continually detecting and intervening in areas of concern, problems and “small” errors before they are allowed to produce adverse outcomes. The hospitals we work with have those mechanisms and the appropriate culture in place to continually improve and fix things ‘before’ they break. Unfortunately in healthcare today we are obsessed with having reactive ‘reporting’ systems used when we fail rather than having proactive ‘recording’ systems that engage everyone 24/7 that help us prevent failure. HROs are in essence ‘learning organizations’ that have mechanisms and processes in place that help them continually improve.



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