What health care is learning from the aviation industry

A Retrospective Review of Serious Surgical Incidents in 5 Large UK Teaching Hospitals: A System-Based Approach

OBJECTIVES

Surgical incidents are the most common serious patient safety incidents worldwide. We conducted a review of serious surgical incidents recorded in 5 large teaching hospitals located in one London NHS trust to identify possible contributing factors and propose recommendations for safer healthcare systems.

METHODS

We searched the Datix system for all serious surgical incidents that occurred in any operating room, excluding critical care departments, and were recorded between October 2014 and December 2016. We used the London Protocol system analysis framework, which involved a 2-stage approach. A brief description of each incident was produced, and an expert panel analyzed these incidents to identify the most likely contributing factors and what changes should be recommended.

RESULTS

One thousand fifty-one surgical incidents were recorded, 14 of which were categorized as "serious" with contributing factors relating to task, equipment and resources, teamwork, work environmental, and organizational and management. Operating room protocols were found to be unavailable, outdated, or not followed correctly in 8 incidents studied. The World Health Organization surgical safety checklist was not adhered to in 8 incidents, with the surgical and anesthetic team not informed about faulty equipment or product shortages before surgery. The lack of effective communication within multidisciplinary teams and inadequate medical staffing levels were perceived to have contributed.

CONCLUSIONS

Multiple factors contributed to the occurrence of serious surgical incidents, many of which related to human failures and faulty equipment. The use of faulty equipment needs to be recognized as a major risk within departments and promptly addressed.

Learning from safety incidents in high-reliability organizations: a systematic review of learning tools that could be adapted and used in healthcare

OBJECTIVE

A high-reliability organization (HRO) is an organization that has sustained almost error-free performance, despite operating in hazardous conditions where the consequences of errors could be catastrophic. A number of tools and initiatives have been used within HROs to learn from safety incidents, some of which have the potential to be adapted and used in healthcare. We conducted a systematic review to identify any learning tools deemed to be effective that could be adapted and used by multidisciplinary teams in healthcare following a patient safety incident.

METHODS

This review followed the Preferred Reporting Items for Systematic Reviews and MetaAnalyses for Protocols reporting guidelines and was registered with the PROSPERO (CRD42017071528). A search of databases was carried out in January 2021, from the date of their commencement. We conducted a search on electronic databases such as Web of Science, Science Direct, MEDLINE in Process Jan 1950-present, EMBASE Jan 1974-present, CINAHL 1982-present, PsycINFO 1967-present, Scopus and Google Scholar. We also searched the grey literature including reports from government agencies, relevant doctoral dissertations and conference proceedings. A customized data extraction form was used to capture pertinent information from included studies and Critical Appraisal Skills Programme tool to appraise on their quality.

RESULTS

A total of 5921 articles were identified, with 964 duplicate articles removed and 4932 excluded at the title (4055), abstract (510) and full-text (367) stages. Twenty-five articles were included in the review. Learning tools identified included debriefing, simulation, crew resource management and reporting systems to disseminate safety messages. Debriefing involved deconstructing incidents using reflective questions, whilst simulation training involved asking staff to relive the event again by performing the task(s) in a role-play scenario. Crew resource management is a set of training procedures that focus on communication, leadership and decision-making. Sophisticated incident-reporting systems provide valuable information on hazards and were widely recommended as a way of disseminating key safety messages following safety incidents. These learning tools were found to have a positive impact on learning if conducted soon after the incident with efficient facilitation.

CONCLUSION

Healthcare organizations should find ways to adapt to the learning tools or initiatives used in HROs following safety incidents. It is challenging to recommend any specific one as all learning tools have shown considerable promise. However, the way these tools or initiatives are implemented is critical, and so further work is needed to explore how to successfully embed them into healthcare organizations so that everyone at every level of the organization embraces them.

Applying safety lessons from aviation to pre-licensure health professions education: A narrative critical review

BACKGROUND

Significant numbers of patients continue to be harmed annually by healthcare systems in the United States (US) and around the world. Through a lens of safety, the fields of aviation and healthcare share many similarities in the non-technical skills required by team members, including situational awareness, communication, problem-solving, and leadership. Despite these links and evidence of effective interventions in the clinical setting, there is a lack of a guidance on how to incorporate non-technical skills training into pre-licensure health professions curricula.

METHODS

Following guidance for a narrative critical review, a comprehensive literature search was conducted looking for studies incorporating non-technical skills training including crew resource management (CRM) and human factors and ergonomics (HFE) into pre-licensure health professions curricula.

RESULTS

Eleven example articles were organized into three broad themes: (1) changing the teaching paradigm around errors, (2) targeted curricular interventions, and (3) interprofessional team training. Several useful tools for evaluating training effectiveness were highlighted, but consistent measures of efficacy for CRM/HFE training are lacking. Interprofessional team training may have the most tangible and broadly applicable link to pre-licensure curricula.

IMPLICATIONS

Additional research is needed to identify best practices for consistent incorporation of non-technical skills into pre-licensure curricula. A cultural shift to focus on error management (vs. solely error avoidance) is also needed early in training with development of a common language to discuss patient safety issues and opportunities for improvement across various healthcare settings.