On error management: lessons from aviation

doi:10.1136/bmj.320.7237.781

BMJ 2000;320:781-785 ( 18 March )

Education and debate

On error management: lessons from aviation

Robert L Helmreich, professor of psychology.

Department of Psychology, University of Texas at Austin, Austin, TX 78712, USA

helmreich@psy.utexas.edu

The first 150 words of the full text of this article appear below.

Pilots and doctors operate in complex environments where teams interact with technology. In both domains, risk varies fromlow to high with threats coming from a variety of sources in theenvironment. Safety is paramount for both professions, but costissues can influence the commitment of resources for safety efforts.Aircraft accidents are infrequent, highly visible, and often involvemassive loss of life, resulting in exhaustive investigation intocausal factors, public reports, and remedial action. Researchby the National Aeronautics and Space Administration into aviationaccidents has found that 70% involve human error.¹

In contrast, medical adverse events happen to individual patients and seldom receive national publicity. More importantly,there is no standardised method of investigation, documentation,and dissemination. The US Institute of Medicine estimates thateach year between 44 000 and 98 000 people die as a result ofmedical errors. When error is suspected, litigation and new regulationsare threats . . . [Full text of this article]

CiteULike

Complore

Connotea

Del.icio.us Add to Digg

Digg

StumbleUpon Add to Technorati

Technorati What's this?

Relevant Articles

Rate of undesirable events at beginning of academic year: retrospective cohort study: Guy Haller, Paul S Myles, Patrick Taffé, Thomas V Perneger, and Christopher L Wu
BMJ 2009 339: b3974. [Abstract] [Full Text] [PDF]

Improving patient safety through training in non-technical skills: Rhona Flin and Rona Patey
BMJ 2009 339: b3595. [Extract] [Full Text]

Reducing error, improving safety: Victor Barley, Graham Neale, Christopher Burns-Cox, Paul Savage, Sam Machin, Adel El-Sobky, Anne Savage, Aziz Sheikh, Brian Hurwitz, C K Connolly, Pia Maria Jonsson, Göran Tomson, Lars Räf, Ken McCune, Ron Law, Roger M Goss, Anonymous, Carlos A Estrada, James Carter, Clyde Brooks, Ann C Jobe, Jonathan Aldridge, Peter Freeland, Brenda Ashcroft, Max Eistein, Nicholas Boreham, Peter J Shirley, Leo Strunin, Maldwyn Morgan, Paul Cartwright, and Robert P Coffey
BMJ 2000 321: 505. [Extract] [Full Text] [PDF]

Anaesthesiology as a model for patient safety in health care: David M Gaba
BMJ 2000 320: 785-788. [Extract] [Full Text] [PDF]

This article has been cited by other articles:

Clay-Williams, R., Braithwaite, J. (2009). Determination of health-care teamwork training competencies: a Delphi study. Int J Qual Health Care 21: 433-440 [Abstract] [Full text]
Haller, G., Myles, P. S, Taffe, P., Perneger, T. V, Wu, C. L (2009). Rate of undesirable events at beginning of academic year: retrospective cohort study. BMJ 339: b3974-b3974 [Abstract] [Full text]
Flin, R., Patey, R. (2009). Improving patient safety through training in non-technical skills. BMJ 339: b3595-b3595 [Full text]
Singh, N. (2009). On a wing and a prayer: surgeons learning from the aviation industry. JRSM 102: 360-364 [Full text]
Eisen, L. A., Savel, R. H. (2009). What Went Right: Lessons for the Intensivist From the Crew of US Airways Flight 1549. Chest 136: 910-917 [Abstract] [Full text]
Tschan, F., Semmer, N. K., Gurtner, A., Bizzari, L., Spychiger, M., Breuer, M., Marsch, S. U. (2009). Explicit Reasoning, Confirmation Bias, and Illusory Transactive Memory: A Simulation Study of Group Medical Decision Making. Small Group Research 40: 271-300 [Abstract]
Mishra, A, Catchpole, K, McCulloch, P (2009). The Oxford NOTECHS System: reliability and validity of a tool for measuring teamwork behaviour in the operating theatre. Qual Saf Health Care 18: 104-108 [Abstract] [Full text]
de Vries, E N, Hollmann, M W, Smorenburg, S M, Gouma, D J, Boermeester, M A (2009). Development and validation of the SURgical PAtient Safety System (SURPASS) checklist. Qual Saf Health Care 18: 121-126 [Abstract] [Full text]
Barach, P., Johnson, J. K., Ahmad, A., Galvan, C., Bognar, A., Duncan, R., Starr, J. P., Bacha, E. A. (2008). A prospective observational study of human factors, adverse events, and patient outcomes in surgery for pediatric cardiac disease.. J. Thorac. Cardiovasc. Surg. 136: 1422-1428 [Abstract] [Full text]
ElBardissi, A. W., Wiegmann, D. A., Henrickson, S., Wadhera, R., Sundt, T. M. III (2008). Identifying methods to improve heart surgery: an operative approach and strategy for implementation on an organizational level. Eur. J. Cardiothorac. Surg. 34: 1027-1033 [Abstract] [Full text]
Clarke, I. (2008). Learning from critical incidents. Adv. Psychiatr. Treat. 14: 460-468 [Abstract] [Full text]
Haller, G., Garnerin, P., Morales, M.-A., Pfister, R., Berner, M., Irion, O., Clergue, F., Kern, C. (2008). Effect of crew resource management training in a multidisciplinary obstetrical setting. Int J Qual Health Care 20: 254-263 [Abstract] [Full text]
van der Sijs, H., Aarts, J., van Gelder, T., Berg, M., Vulto, A. (2008). Turning Off Frequently Overridden Drug Alerts: Limited Opportunities for Doing It Safely. J. Am. Med. Inform. Assoc. 15: 439-448 [Abstract] [Full text]
Hales, B., Terblanche, M., Fowler, R., Sibbald, W. (2008). Development of medical checklists for improved quality of patient care. Int J Qual Health Care 20: 22-30 [Abstract] [Full text]
Lingard, L., Regehr, G., Orser, B., Reznick, R., Baker, G. R., Doran, D., Espin, S., Bohnen, J., Whyte, S. (2008). Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication. Arch Surg 143: 12-17 [Abstract] [Full text]
Garbutt, J., Waterman, A. D., Kapp, J. M., Dunagan, W. C., Levinson, W., Fraser, V., Gallagher, T. H. (2008). Lost Opportunities: How Physicians Communicate About Medical Errors. Health Aff (Millwood) 27: 246-255 [Abstract] [Full text]
Taylor, J. A., Loan, L. A., Kamara, J., Blackburn, S., Whitney, D. (2008). Medication Administration Variances Before and After Implementation of Computerized Physician Order Entry in a Neonatal Intensive Care Unit. Pediatrics 121: 123-128 [Abstract] [Full text]
Singh, H., Thomas, E. J., Petersen, L. A., Studdert, D. M. (2007). Medical Errors Involving Trainees: A Study of Closed Malpractice Claims From 5 Insurers. Arch Intern Med 167: 2030-2036 [Abstract] [Full text]
Taylor, C. R, Hepworth, J. T, Buerhaus, P. I, Dittus, R., Speroff, T. (2007). Effect of crew resource management on diabetes care and patient outcomes in an inner-city primary care clinic. Qual Saf Health Care 16: 244-247 [Abstract] [Full text]
Patey, R., Flin, R., Cuthbertson, B. H, MacDonald, L., Mearns, K., Cleland, J., Williams, D. (2007). Patient safety: helping medical students understand error in healthcare. Qual Saf Health Care 16: 256-259 [Abstract] [Full text]
Williams, M V (2007). Improving patient safety in radiotherapy by learning from near misses, incidents and errors. Br. J. Radiol. 80: 297-301 [Abstract] [Full text]
Stebbing, C., Wong, I. C K, Kaushal, R., Jaffe, A. (2007). The role of communication in paediatric drug safety. Arch. Dis. Child. 92: 440-445 [Abstract] [Full text]
Norton, P. G., Baker, G. R. (2007). Patient Safety in Cancer Care: A Time for Action. JNCI J Natl Cancer Inst 99: 579-580 [Full text]
O'Connor, P., O'Dea, A., Melton, J. (2007). A Methodology for Identifying Human Error in U.S. Navy Diving Accidents. Human Factors: The Journal of the Human Factors and Ergonomics Society 49: 214-226 [Abstract]
Gunderman, R. B., Burdick, E. J. (2007). Error and Opportunity. Am. J. Roentgenol. 188: 901-903 [Full text]
Parnes, B., Fernald, D., Quintela, J., Araya-Guerra, R., Westfall, J., Harris, D., Pace, W. (2007). Stopping the error cascade: a report on ameliorators from the ASIPS collaborative. Qual Saf Health Care 16: 12-16 [Abstract] [Full text]
Katz-Navon, T., Naveh, E., Stern, Z. (2007). The moderate success of quality of care improvement efforts: three observations on the situation. Int J Qual Health Care 19: 4-7 [Abstract] [Full text]
Garbutt, J., Brownstein, D. R., Klein, E. J., Waterman, A., Krauss, M. J., Marcuse, E. K., Hazel, E., Dunagan, Wm. C., Fraser, V., Gallagher, T. H. (2007). Reporting and Disclosing Medical Errors: Pediatricians' Attitudes and Behaviors. Arch Pediatr Adolesc Med 161: 179-185 [Abstract] [Full text]
McMaster, P, Rogers, D, Kerr, M, Spencer, A (2007). Getting guidelines to work in practice. Arch. Dis. Child. 92: 104-106 [Full text]
Morgan, O., Pencheon, D. (2006). Make it boring: letter to the Journal of Public Health. J Public Health (Oxf) 28: 394-395 [Full text]
Galbraith, R M, Holtman, M C, Clyman, S G (2006). Use of assessment to reinforce patient safety as a habit. Qual Saf Health Care 15: i30-i33 [Abstract] [Full text]
Amalberti, R, Vincent, C, Auroy, Y, de Saint Maurice, G (2006). Violations and migrations in health care: a framework for understanding and management. Qual Saf Health Care 15: i66-i71 [Abstract] [Full text]
Ohlinger, J., Kantak, A., Lavin, J. P. Jr, Fofah, O., Hagen, E., Suresh, G., Halamek, L. P., Schriefer, J. A. (2006). Evaluation and Development of Potentially Better Practices for Perinatal and Neonatal Communication and Collaboration. Pediatrics 118: S147-S152 [Abstract] [Full text]
Legant, P. (2006). Oncologists and Medical Malpractice. J Oncol Pract 2: 164-169 [Full text]
McGugan, L A, Maran, N J, Glavin, R, Nichol, N (2006). Accident and emergency training perspectives in Scotland.. Emerg. Med. J. 23: 512-514 [Abstract] [Full text]
Horwitz, L. I., Krumholz, H. M., Green, M. L., Huot, S. J. (2006). Transfers of patient care between house staff on internal medicine wards: a national survey.. Arch Intern Med 166: 1173-1177 [Abstract] [Full text]
Smith, A. F., Goodwin, D., Mort, M., Pope, C. (2006). Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting.. Br J Anaesth 96: 715-721 [Abstract] [Full text]
Stebbing, C., Kaushal, R., Bates, D. W. (2006). Pediatric medication safety and the media: what does the public see?. Pediatrics 117: 1907-1914 [Abstract] [Full text]
Fassett, W. E (2006). Patient Safety and Quality Improvement Act of 2005. The Annals of Pharmacotherapy 40: 917-924 [Abstract] [Full text]
Tan, J A, Naik, V N, Lingard, L (2006). Exploring obstacles to proper timing of prophylactic antibiotics for surgical site infections. Qual Saf Health Care 15: 32-38 [Abstract] [Full text]
Wagner, L. M., Capezuti, E., Taylor, J. A., Sattin, R. W., Ouslander, J. G. (2005). Impact of a Falls Menu-Driven Incident-Reporting System on Documentation and Quality Improvement in Nursing Homes. Gerontologist 45: 835-842 [Abstract] [Full text]
Mckinney, E. H. Jr., Barker, J. R., Davis, K. J., Smith, D. (2005). How Swift Starting Action Teams Get off the Ground: What United Flight 232 and Airline Flight Crews Can Tell Us About Team Communication. Management Communication Quarterly 19: 198-237 [Abstract]
Lingard, L, Espin, S, Rubin, B, Whyte, S, Colmenares, M, Baker, G R, Doran, D, Grober, E, Orser, B, Bohnen, J, Reznick, R (2005). Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR. Qual Saf Health Care 14: 340-346 [Abstract] [Full text]
Coyle, Y M, Mercer, S Q, Murphy-Cullen, C L, Schneider, G W, Hynan, L S (2005). Effectiveness of a graduate medical education program for improving medical event reporting attitude and behavior. Qual Saf Health Care 14: 383-388 [Abstract] [Full text]
Svenmarker, S., Appelblad, M. (2005). Reporting of perfusion-related incidents: pitfalls and limitations. Perfusion 20: 243-248
Wilson, K A, Burke, C S, Priest, H A, Salas, E (2005). Promoting health care safety through training high reliability teams. Qual Saf Health Care 14: 303-309 [Abstract] [Full text]
Mello, M. M., Kelly, C. N., Brennan, T. A. (2005). Fostering Rational Regulation of Patient Safety. Journal of Health Politics, Policy and Law 30: 375-426 [Abstract]
Schmidek, J M, Weeks, W B (2005). Relationship between tort claims and patient incident reports in the Veterans Health Administration. Qual Saf Health Care 14: 117-122 [Abstract] [Full text]
Allinson, T. T., Szeinbach, S. L., Schneider, P. J. (2005). Perceived accuracy of drug orders transmitted orally by telephone. Am J Health Syst Pharm 62: 78-83 [Full text]
Tang, B., Hanna, G. B., Joice, P., Cuschieri, A. (2004). Identification and Categorization of Technical Errors by Observational Clinical Human Reliability Assessment (OCHRA) During Laparoscopic Cholecystectomy. Arch Surg 139: 1215-1220 [Abstract] [Full text]
Lingard, L, Espin, S, Whyte, S, Regehr, G, Baker, G R, Reznick, R, Bohnen, J, Orser, B, Doran, D, Grober, E (2004). Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care 13: 330-334 [Abstract] [Full text]
Ricci, M, Goldman, A P, de Leval, M R, Cohen, G A, Devaney, F, Carthey, J (2004). Pitfalls of adverse event reporting in paediatric cardiac intensive care. Arch. Dis. Child. 89: 856-859 [Abstract] [Full text]
Fernald, D. H., Pace, W. D., Harris, D. M., West, D. R., Main, D. S., Westfall, J. M. (2004). Event Reporting to a Primary Care Patient Safety Reporting System: A Report From the ASIPS Collaborative. Ann Fam Med 2: 327-332 [Abstract] [Full text]
Bowie, P, McKay, J, Norrie, J, Lough, M (2004). Awareness and analysis of a significant event by general practitioners: a cross sectional survey. Qual Saf Health Care 13: 102-107 [Abstract] [Full text]
Hoff, T., Jameson, L., Hannan, E., Flink, E. (2004). A Review of the Literature Examining Linkages between Organizational Factors, Medical Errors, and Patient Safety. Med Care Res Rev 61: 3-37 [Abstract]
Firth-Cozens, J (2004). Organisational trust: the keystone to patient safety. Qual Saf Health Care 13: 56-61 [Abstract] [Full text]
Pronovost, P J, Weast, B, Holzmueller, C G, Rosenstein, B J, Kidwell, R P, Haller, K B, Feroli, E R, Sexton, J B, Rubin, H R (2003). Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center. Qual Saf Health Care 12: 405-410 [Abstract] [Full text]
Rubin, G, George, A, Chinn, D J, Richardson, C (2003). Errors in general practice: development of an error classification and pilot study of a method for detecting errors. Qual Saf Health Care 12: 443-447 [Abstract] [Full text]
Parker, D, Lawton, R (2003). Psychological contribution to the understanding of adverse events in health care. Qual Saf Health Care 12: 453-457 [Abstract] [Full text]
Battles, J B, Lilford, R J (2003). Organizing patient safety research to identify risks and hazards. Qual Saf Health Care 12: ii2-7 [Abstract] [Full text]
Carthey, J (2003). The role of structured observational research in health care. Qual Saf Health Care 12: ii13-16 [Abstract] [Full text]
Kuzel, A. J., Woolf, S. H., Engel, J. D., Gilchrist, V. J., Frankel, R. M., LaVeist, T. A., Vincent, C. (2003). Making the Case for a Qualitative Study of Medical Errors in Primary Care. Qual Health Res 13: 743-780 [Abstract]
Sandars, J., Esmail, A. (2003). The frequency and nature of medical error in primary care: understanding the diversity across studies. Fam Pract 20: 231-236 [Abstract] [Full text]
de Leval, M. R. (2003). Beyond Flatland. J. Thorac. Cardiovasc. Surg. 125: 12-19 [Full text]
Womer, R. B., Tracy, E., Soo-Hoo, W., Bickert, B., DiTaranto, S., Barnsteiner, J. H. (2002). Multidisciplinary Systems Approach to Chemotherapy Safety: Rebuilding Processes and Holding the Gains. JCO 20: 4705-4712 [Abstract] [Full text]
Leape, L. L., Berwick, D. M., Bates, D. W. (2002). What Practices Will Most Improve Safety?: Evidence-Based Medicine Meets Patient Safety. JAMA 288: 501-507 [Full text]
Chassin, M. R., Becher, E. C. (2002). The Wrong Patient. ANN INTERN MED 136: 826-833 [Abstract] [Full text]
Aron, D C, Headrick, L A (2002). Educating physicians prepared to improve care and safety is no accident: it requires a systematic approach. Qual Saf Health Care 11: 168-173 [Abstract] [Full text]
Fletcher, G. C. L., McGeorge, P., Flin, R. H., Glavin, R. J., Maran, N. J. (2002). The role of non-technical skills in anaesthesia: a review of current literature. Br J Anaesth 88: 418-429 [Abstract] [Full text]
Hartlieb, M. C., Sibbald, W. J. (2002). Simple Interventions-Significant Impact. Am. J. Respir. Crit. Care Med. 165: 434-435 [Full text]
Epstein, R. M., Hundert, E. M. (2002). Defining and Assessing Professional Competence. JAMA 287: 226-235 [Abstract] [Full text]
Davies, J. M. (2001). Painful inquiries: lessons from Winnipeg. CMAJ 165: 1503-1504 [Full text]
Field, T. S., Gurwitz, J. H., Avorn, J., McCormick, D., Jain, S., Eckler, M., Benser, M., Bates, D. W. (2001). Risk Factors for Adverse Drug Events Among Nursing Home Residents. Arch Intern Med 161: 1629-1634 [Abstract] [Full text]
Young, P., Hamilton, R., Hodgett, S., Moss, M., Rigby, C., Jones, P., Johanson, R. (2001). Reducing risk by improving standards of intrapartum fetal care. JRSM 94: 226-231 [Abstract] [Full text]
Becher, E. C., Chassin, M. R. (2001). Improving Quality, Minimizing Error: Making It Happen. Health Aff (Millwood) 20: 68-81 [Abstract] [Full text]
Barley, V., Neale, G., Burns-Cox, C., Savage, P., Machin, S., El-Sobky, A., Savage, A., Sheikh, A., Hurwitz, B., Connolly, C K, Jonsson, P. M., Tomson, G., Räf, L., McCune, K., Law, R., Goss, R. M, Anonymous, , Estrada, C. A, Carter, J., Brooks, C., Jobe, A. C, Aldridge, J., Freeland, P., Ashcroft, B., Eistein, M., Boreham, N., Shirley, P. J, Strunin, L., Morgan, M., Cartwright, P., Coffey, R. P (2000). Reducing error, improving safety. BMJ 321: 505-505 [Full text]
Leape, L. L, Berwick, D. M (2000). Safe health care: are we up to it?. BMJ 320: 725-726 [Full text]
Sexton, J B., Thomas, E. J, Helmreich, R. L (2000). Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ 320: 745-749 [Abstract] [Full text]

Rapid Responses:

Read all Rapid Responses

Should crew resource management training be mandatory in anaesthesia?: Peter J Shirley
bmj.com, 22 Mar 2000 [Full text]
Lessons from aviation: Ken McCune
bmj.com, 19 Apr 2000 [Full text]
Reducing Errors by Preventing Legal Sanctions for Error Reporting: Tess M Pape
bmj.com, 27 Apr 2001 [Full text]