Using aviation safety measures to enhance patient outcomes

Russell M. Rivers

A recent report says that 44,000 to 98,000 Americans die each year as a result of medical errors. (1) This is the equivalent to more than 233 jumbo jets full of people crashing each year. In addition to human loss and suffering, it is estimated that medical errors cost consumers between $17 billion and $29 billion each year in additional care, lost wages, and litigation costs. (2) Consequently, methods of preventing medical errors and increasing patient safety in US medical institutions are being explored. In contrast to a two and one-half fold increase in the number of preventable deaths in medicine during the previous 10 years, the aviation industry has experienced a four-fold decrease in mishaps. In the past 20 years, the aviation industry has decreased errors caused by human factors 50% to 81% through safety training and standardization. (3) This article explores the potential benefits of applying these same safety training techniques and standardization practices to the health care arena.

HEALTH CARE MEETS AVIATION

Methodist University Hospital (MUH) in Memphis is the base hospital for the Methodist Health Care System. In addition to the base hospital, there are three satellite acute care facilities, a pediatric specialty hospital, and three freestanding surgery centers. The base hospital has 33 multispecialty OR suites. During the past seven years, Methodist has experienced a substantial increase in demand at its facilities. With this increasing demand, many of the more experienced nurses opted to move to the satellite facilities closer to their homes. This migration led to the need to expand the pool of perioperative nurses within the system by increasing the number of new staff members in the perioperative training program.

Methodist University Hospital, located in the heart of the city, serves as the tertiary center for referrals of more complicated procedures in the tri-state area. These referrals, along with the hospital's affiliation with university teaching programs, make it a mecca of new technology and innovation. Additionally, MUH serves as a level-two trauma center. Consequently, it is an ideal training ground for its affiliated institutions, and it houses the core training program for all new nurses seeking perioperative experience in the system. After completion of the core program, nurses receive an orientation to the specific facilities where they will work.

In addition to the challenges associated with the constant learning curve related to innovations and technology, MUH also is challenged by a constant influx of new perioperative and medical staff members. Not unlike staff members at other facilities of its size, staff members at MUH must deal with ever changing instrumentation, increases in the number of multiple setups; a flood of new surgeons and techniques, and increased focus on productivity and turnover time reduction. The need for standardization of processes and communication techniques is paramount to help staff members balance changing demands while continuing to provide safe perioperative care.

During the early months of 2001, administrative staff members were working with a local consulting firm to identify ways to reduce the cycle time related to patient admissions. One consulting team member recently had been in contact with a local firm involved in aviation safety training. This firm was looking for a health care organization interested in exploring ways aviation safety principles could be used in health care.

WORKING TOGETHER

After several meetings between the two firms, Methodist Health Care agreed to allow the aviation training firm to spend time with surgical services staff members. The objective was to determine whether there were, in fact, similarities between the two industries and, if so, to evaluate the possible benefits of applying aviation safety training techniques to the surgical services staff member development plan.

Members of the aviation training firm introduced MUH surgical services management staff members to the concept of crew resource management. Crew resource management is a program of aviation safety training, team skills training, safety practices, and tools designed as countermeasures to decrease the number of aviation accidents. Crew resource management training equips pilots and crew members who operate in high-risk, stressful, error-intolerant environments with the team skills to communicate, react to adverse events, employ crosschecking behaviors, manage errors, and make effective decisions under stress. Successful crew resource management programs have been shown to reduce aviation mishaps between 50% and 81%2 The US military and militaries worldwide have used this training program.

At first, surgical services management team members were skeptical of the idea. How could anyone outside of health care understand the challenges faced by physicians and professional medical staff members caring for patients in life-threatening situations? They questioned how the aviation industry could teach them anything about safety and reducing errors and what the aviation and health care industries have in common.

PARALLELS DISCOVERED

The crew resource management introductory presentation began with a videotape of actual footage of a pilot engaged in a bombing mission during Desert Storm. The videotape gave the pilot's view of enemy missiles directed toward his plane and other planes as he returned from the bombing expedition. Viewers could hear numerous verbal instructions the pilot received from crew members of other aircraft and members of his flight crew who were attempting to help him maneuver around the missiles to safety. The missile tracks, which are smoke trails left by missiles as they make their way to their target, bombarding the plane coupled with the reactions and increased respiration of the pilot quickly gave viewers an appreciation of the situation's intensity. The narrator pointed out instances where the pilot's actions were counter to the directions being given, as well as standard techniques usually employed during attacks. The narrator also drew attention to the repetitive communication efforts and techniques used by team members to help the pilot focus on the situation and return safely.

Those in attendance were humbled by the intensity of the videotape and very quickly were able to identify the first parallel between the two industries--stress. Further discussion revealed three other parallels--the need for highly functioning teams, the importance of accurate and precise communication, and the high cost associated with system failures.

BRINGING AVIATION TECHNIQUES INTO THE OR

The next step was to introduce the aviation training team to the surgical services environment. Team members toured perioperative suites and interviewed perioperative team members, including circulating nurses, scrub persons, surgeons, and anesthesia care providers. They observed surgical procedures to get a sense of the team dynamics employed during all phases of surgical procedures. They particularly were interested in the flow of information between team members and the processes involved with procedure preparation.

Several weeks later, the aviation training team submitted a proposal to conduct crew resource management training for members of the perioperative staff. The proposal initially centered on three areas-team formation, early recognition of adverse situations (ie, red flags), and effective communication. Although this training was geared toward improving all aspects of care, perioperative management team members were asked to identify a specific process or function that easily could be measured and was in need of improvement.

Management team members at MUH chose the surgical count process to be used to measure the effectiveness of the training program. The number of unreconcilable surgical counts had been increasing, and radiological intervention increasingly was required to rule out the possibility of item retention. Most of the errors in reconciling counts were related to multiple set ups and changing instrumentation. Additionally, because many of the more complicated procedures overlapped shills, the introduction of new team members added to the complexity of accounting for all objects. Management team members recognized that inaccurate counts were costly in terms of OR time and the expense associated with radiological intervention. They were disturbed even more by the fact that the time-proven methodology of counting objects had become so unreliable.

Pretraining assessment of perioperative staff members, along with data collection, produced three program objectives. These included

* changing the attitudes of surgical services personnel regarding the importance and value of team skills to patient safety;

* improving patient safety and quality of care by equipping personnel with team building, communication, and decision-making skills; and

* reducing the number of count errors through training and application of aviation safety tools.

TRAINING

The aviation training firm conducted 12 hours of skills-based interactive training sessions for the 164 surgical services staff members. The training was divided into three four-hour phases (Table 1). Each phase included multiple case studies, interactive team activities and skill applications, video modeling of desired performance, and knowledge testing. The goal of each module was to provide participants with specific skills that could be used in their environment upon completion of training to successfully reduce errors immediately. These skills later were applied specifically to the surgical count process. Additionally, the aviation safety firm designed a confidential, nonpunitive, over-the-shoulder data collection form that surgical services staff members could use to document the use of dynamic outcomes management skills (ie, skills for managing resources toward positive patient outcomes) during the actual performance of their duties in the surgical suite. This tool can be used by staff members to evaluate themselves or other members of the surgical team.

Methodist University Hospital personnel participated in the development of specific aviation-based safety tools and learned how to use them in the OR to reduce count errors. The primary tool developed as a result of this effort was a challenge and response checklist that is similar to aviation's pretakeoff checklist. The use of this checklist in the OR was instituted during the training program and was instrumental in reducing the risk of an incorrect count during any portion of a surgical procedure.

RESULTS

Significant improvements were noted in three areas. First, there was a positive shift in participants' attitudes toward the value of team skills. Second, there was improvement in communication skills. Third, and most importantly, there was a significant decrease in surgical counting errors.

Attitude change toward the value of team skills. Surgical services staff members completed human factors attitude questionnaires before and after training. These questionnaires measured and analyzed attitudes toward the use of team skills for improving the level of patient safety and quality care. Successful training has been shown to positively shift the attitudes of participants toward the use of team skills, and positive attitude shift has been shown to be indicative of improved operational performance. (5) The surveys revealed that the training had a significant effect on desired behaviors. Based on these results, MUH should see improved performance by surgical services staff members in the following skill sets:

* inquiry (ie, asking questions when unsure),

* preprocedure team building,

* preprocedure briefings,

* communication during unexpected events,

* assertion,

* recognition of possible adverse events, and

* postprocedure debriefing (ie, critiques, reviews).

Further data collection through over-the-shoulder assessments, structured interviews, and critical incident reports will be necessary to document the anticipated performance improvements.

Improvement in communication skills. All participants completed post-training surveys designed to examine whether they perceived the training as valuable. Responses were collected and analyzed using a five-point Liken-type scale. More than 75% of staff members strongly or very strongly agreed that dynamic outcomes management training provided useful knowledge for improving actual job skills. More than 81% strongly or very strongly agreed that dynamic outcomes, management training would increase their effectiveness in the OR. As the foundation of this training rests on effective communication, these high percentages suggest that staff members believe communication will improve.

Surgical counting error reduction. Dynamic outcomes management training decreased the number of surgical count errors by 50%. Aviation training team members analyzed the number of errors related to counts during a six-month period before training and compared this to data compiled during the six months during and after training. The number of surgical procedures performed during each segment was not significantly different. Analysis showed a 50% reduction in the number of incorrect counts during the second six-month segment. Interviews with staff members and administrators revealed no unusual staff turnover or other significant changes (eg, data collection methods, chain of custody for data, reporting methods).

IMPLICATIONS

The benefits of standardizing processes and improving team skills affect many aspects of perioperative nursing. For example, training new staff members becomes much smoother, and possibly faster, when all team members perform similarly and communicate effectively. Learning curves can be decreased greatly. Procedure delays are minimized when team members effectively communicate and use standardized checklists to ensure that all supplies, diagnostic studies, and laboratory reports are available when needed. Valuable OR time and resources can be saved.

Errors occur less frequently with the reduction of randomness. For example, counting instruments and needles becomes much more routine when instrument setups are standardized and communication techniques are consistent. Changes in care, such as during shift changes, present much less risk when procedures and processes are standardized and pertinent information is transferred adequately. The ability of team members to recognize and effectively communicate red flags can prevent possible mishaps and many of the subsequent losses that often occur. It is difficult to estimate the potential savings associated with a 50% reduction in counting errors, but considering the high cost of litigation associated with cases involving retained objects, this reduction is of obvious value.

SUMMARY

This project clearly demonstrates that there are benefits to providing aviation safety and standardization training to health care professionals. After staff members discovered similarities between the industries, they eagerly embraced the techniques introduced. They demonstrated attitudinal changes in the direction of more highly functioning teams. They also found the training to be effective in teaching new job skills, such as the ability to identify red flags and prevent near misses by communicating more effectively with other team members before a situation deteriorates into a possible sentinel event. Most importantly, staff members were able to apply the newly learned skills to a critical area of practice and demonstrate significant improvement. Though more analysis is required, future training in other time-sensitive, patient critical areas should produce similar results.

Table 1

Phase I
Introduction
Building an effective team
Recognizing adverse situations
Managing conflict

Phase II
Stress management and countermeasures
Decision making
Performance feedback

Phase III
Course review
Cross check and challenge
Fatigue management and countermeasures

NOTES

1. Institute of Medicine, To Err is Human: Building a Safer Health System (Washington, DC: National Academy Press, 2000) 1.

2. Ibid, 27.

3. G Grubb, J C Morey, R Simon, "Sustaining and advancing performance improvements achieved by crew resource management training," seminar presented at the Ohio State Aviation Psychology Symposium, Ohio, 2001.

4. Ibid.

5. R L Helmreich et al, "Cockpit resource management: Exploring the attitude-performance linkage," Aviation, Space, and Environmental Medicine 57 (December 1986) 1198-1200.

Russell M. Rivers, BS, was the lead instructor and client manager of the health care division, Crew Training International, Inc, Memphis, at the time this article was written. He also is a lieutenant colonel in the US Marine Corps Reserves.

Diane Swain, RN, BSN, MBA, is the administrative director, cardiovascular services, Methodist Hospital, Germantown, Tenn.

William R. Nixon, BME, MA, is senior instructional system developer, Crew Training International, Inc, Memphis.

COPYRIGHT 2003 Association of Operating Room Nurses, Inc.
COPYRIGHT 2003 Gale Group