A Military Aviation model for Patient Safety?

In the September 2013 edition of the British Medical Journal, Robyn Clay-Williams has published a thought provoking article on the modelling of clinical risk management on civil aviation practices, and questions whether a military aviation model may be more prudent when assessing and managing risk in the healthcare environment.  The abstract can be found HERE.

The author questions the appropriateness of translating sometimes rigid civil aviation processes (and a zero tolerance for risk) into healthcare, as some healthcare systems (such as emergency departments and intensive care units) need more flexibility and autonomy in their workings and risk management. She suggests managing risk in high stakes clinical environments such as these would be more conducive to a military aviation model – the parallels being teams with limited resources who deal routinely with unpredictable situations, complex and time critical operations (as would happen frequently in the pre-hospital environment or the ED resus room).

Suggestions for improving the adaptability and resilience of health care organizations in the realms of risk management derived from a military model include:

  • planning for the unexpected
  • training for the worst: simulation training of worst case scenarios allows decision making under pressure and can help develop spare capacity
  • training disparate teams together: multidisciplinary and inter-departmental simulation training
  • learning about the limits of human performance
  • supported simulation allowing development of
    • self-awareness
    • contingency planning
    • communication skills.

At Auckland ED we have begun multi-disciplinary simulation afternoons with other clinical departments, out first event included HEMS, Emergency Department, Trauma Surgery, Cardiothoracics, Anaesthetics and Operating Theatres.  This was invaluable in ‘testing the system’ involving handover, clinical management, resourcing (labs, radiology, blood bank, theatre) and most especially inter-departmental communication and teamwork.  Our first simulation has garnered resounding positive feedback from all involved.

I would be interested in comments from others who are doing inter-departmental simulation and team training.

Click HERE for the full version of the article discussed above (secure area limited to ADHB staff)


Analysing communication errors in an air medical transport service

The importance of effective communication

The importance of effective communication

A recent study published in the May-June 2013 edition of Air Medical Journal analyzed a randomly selected group of quality assurance reports looking for communication errors. Quality assurance reports examined had been submitted in circumstances of issues, adverse events, or simply high risk activities (for example patient requiring intubation, or scene times exceeding 20 minutes)

Of 278 reports analysed, 58 (21%) were found to involve communication errors. Communication errors were categorised according to Clark’s Communication Level Hierarchy:

Level 1: CHANNEL – establishing a means of communication between people – e.g verbal communication, digital communication

Level 2: SIGNAL – the transmitted data, for example the sound in a verbal communication or the text in a digital communication

Level 3: INTENTION – the semantic meaning derived from the content within the data

Level 4: CONVERSATION – the joint activitiy that is understood between people communication (e.g. shared mental model)

Of 65 communication errors found (from 58 reports), less than a third had been identified by staff as communication errors. Communication errors occurred most commonly at level 1 (42/64) followed by level 4 (21/64). Level 2 and 3 failures were rare.

The most common communication issue was failure to communicate change in plan or status.

The authors concluded that current quality and safety reporting systems may lack the sensitivity to identify communication errors, and that improvements to the ontology of quality and safety reporting systems, user interfaces, and staff education on reporting of communication errors could enhance the safety of air medical transport services.

Read the full article HERE (secure area limited to ADHB staff only – ADHB has subscription access to this journal via the Philson Library at the University of Auckland School of Medicine)

With thanks to Russell Clarke

Errors in prehospital paediatric resuscitation


When compared to adult resuscitation, paediatric resuscitation has anatomical, pharmacological, procedural, social, and emotional differences that may make it more difficult and therefore more prone to error.

The authors of this study (full text pdf – NOT hosted on this site) used a simulated paediatric emergency (infant with altered mental status, seizures, and respiratory arrest) to look at errors in paediatric resuscitation by two person EMS teams.

What emerged were issues regarding equipment familiarity/use/misuse, failure to check BSL, and drug errors. Calculations of drug doses were difficult under stress. Failure rates in some of these domains exceeded 50%.

This study, coupled with our low incidence of significant paediatric resuscitation, suggests that we must have ongoing training in paediatric emergencies (simulation and otherwise) to mitigate these risks, and consider new ways of avoiding error. Given the high rate of smartphone use by HEMS personnel, this app is possibly a good start!