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Content ArticleThe COVID-19 pandemic resulted in an unprecedented reduction in the delivery of surgical services worldwide, especially in non-urgent, non-cancer procedures. A prolonged period without operating (or ‘layoff period’) can result in surgeons experiencing skill fade (both technical and non-technical) and a loss of confidence. While senior surgeons in the UK may be General Medical Council (GMC) validated and capable of performing a procedure, a loss of ‘currency’ may increase the risk of error and intraoperative patient harm, particularly if unexpected or adverse events are encountered. Dual surgeon operating may mitigate risks to patient safety as surgeons regain currency while returning to non-urgent operating and may also be beneficial after the greatly reduced activity observed during the COVID-19 pandemic for low-volume complex operations. In addition, it could be a useful tool for annual appraisal, sharing updated surgical techniques and helping team cohesion. This paper explores lessons from aviation, a leading industry in human factors principles, for regaining surgical skills currency. We discuss real and perceived barriers to dual surgeon operating including finance, training, substantial patient waiting lists, and intraoperative power dynamics.
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Content ArticleMandatory and voluntary safety reporting policies are an extremely important part of providing guidance for safety reporting in aviation safety management systems (SMS). This blog highlights the purpose of safety reporting policies, how to train employees on voluntary vs mandatory reporting, and how to encourage mandatory and voluntary safety reporting. Although written for the aviation industry, many of the principles can be applied to healthcare.
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Content ArticleOn 2 September 2006, all 14 crew of a UK Royal Air Force (RAF) ‘spy plane’ Nimrod XV230 were lost following a catastrophic mid-air fire. The aircraft was on a routine mission when a leak of aviation fuel, shortly after air-to-air refuelling, came into contact with a source of ignition. The fire was not accessible, not able to be remotely suppressed, and the incident was not survivable. ‘The Nimrod Review’, led by The Hon. Mr Justice Haddon-Cave, is a model investigation, and should be required reading for executives and leaders in all industries. The Review takes the aircraft fire as its starting point, but casts its net far and wide through the organisation, as well as considering relevant events in other industries. This Nimrod XV230 tragedy is so rich in lessons, Martin Anderson, Chartered Human Factors Professional, shares on his website a series of articles about the Nimrod XV230.
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Content Article
SKYbrary: Safety occurrence reporting (2 October 2020)
Becky T posted an article in Implementation of improvements
This article, published on SKYbrary, discusses the importance of correct safety reporting in the aviation industry. Safety occurrence reporting aims to improve safety of aircraft operations by timely detection of operational hazards and system deficiencies; the aviation service provider organisations have a legal responsibility to report to their national authorities all accidents or serious incidents of which they become aware. Although for the aviation industry, some of the principles can be applied to healthcare. -
Content ArticleSafety voice is theorised as an important factor for mitigating accidents, but behavioural research during actual hazards has been scant. Research indicates power distance and poor listening to safety concerns (safety listening) suppresses safety voice. Yet, despite fruitful hypotheses and training programmes, data is based on imagined and simulated scenarios and it remains unclear to what extent speaking-up poses a genuine problem for safety management, how negative responses shape the behaviour, or how this can be explained by power distance. Moreover, this means it remains unclear how the concept of safety voice is relevant for understanding accidents. To address this, 172 Cockpit Voice Recorder transcripts of historic aviation accidents were identified, integrated into a novel dataset , coded in terms of safety voice and safety listening and triangulated with Hofstede’s power distance. Results revealed that flight crew spoke-up in all but two accidents, provided the first direct evidence that power distance and safety listening explain variation in safety voice during accidents, and indicated partial effectiveness of CRM training programmes because safety voice and safety listening changed over the course of history, but only for low power distance environments. Thus, findings imply that accidents cannot be assumed to emerge from a lack of safety voice, or that the behaviour is sufficient for avoiding harm, and indicate a need for improving interventions across environments. Findings underscore that the literature should be grounded in real accidents and make safety voice more effective through improving ‘safety listening’.
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Content ArticleInternational Standards and Recommended Practices for aircraft accident and incident investigation.
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Content ArticleThe aim of this study from Mahadevan et al. was to understand human factors (HF) contributing to disturbances during invasive cardiac procedures, including frequency and nature of distractions, and assessment of operator workload. They observed 194 cardiac procedures in three adult cardiac catheterisation laboratories over 6 weeks. The study found that fewer than half of all procedures were completed without interruption/distraction. The majority were unnecessary and without relation to the case or list. The authors propose the introduction of a ‘sterile cockpit’ environment within catheter laboratories, as adapted from aviation and used in surgical operating theatres, to minimise non-emergent interruptions and disturbances, to improve operator conditions and overall patient safety.
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Content ArticleThis issue of Hindsight concerns ‘the new reality’ that we are facing. It includes a wide variety of articles from frontline staff and specialists in safety, human factors, psychology, aeromedical, and human and organisational performance in aviation. There are also insights from healthcare, shipping, rail, community development and psychotherapy.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) report highlights a gap between the NHS and other safety-critical industries in identifying and managing barriers to reduce the risk of serious incidents occurring.
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Event
EuroControl Training Zone webinar
Patient Safety Learning posted an event in Community Calendar
Join the Airport Training Experts Miroslav SPAK and Frederic Rooseleer for a 90 minutes live training session. Enhanced operational efficiency and sustainability can be achieved by optimising the current operations through implementation of advanced solutions maximizing utilisation of the airport capacity. These solutions have been initially developed and validated under SESAR, and recently packaged by EUROCONTROL to cover Runway Performance, Surface Management and Total Airport Management. This webinar will provide information on the total airport management building blocks and also a review of the key runway performance solutions available for deployment as well as their benefits, supporting implementation needs and reference material. Register -
Content ArticleThis chapter from the book 'Learning from High Reliability Organisations' focuses on a systems-based technique for accident analysis referred to as the AcciMap approach. The technique involves the construction of a multi-layered diagram, in which the various causes of an accident are arranged according to their causal remoteness from the outcome. It is particularly useful for establishing how factors in all parts of a sociotechnical system contributed to an organisational accident and for arranging the causes into a coherent diagram that reveals how they interacted to produce that outcome. By identifying these causal factors and the interrelationships between them in this way, it is possible to identify problem areas that should be addressed to improve the safety of the system and prevent similar occurrences in the future.
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Content Article
Safety culture discussion cards (Eurocontrol)
Patient Safety Learning posted an article in Good practice
Safety culture has been shown to be a key predictor of safety performance in several industries. It is the difference between a safe organisation and an accident waiting to happen. Thinking and talking about our safety culture is essential for us to understand what we do well, and where we need to improve. These cards from Eurocontrol are designed to help us to do this. -
Content Article
Learning from excellence in healthcare
Patient Safety Learning posted an article in Implementation of improvements
Learning from everyday work means learning from all activities regardless of the outcome. But when things go well, this is typically just gratefully accepted, without further investigation. ‘Learning from Excellence’ is changing this, as Adrian Plunkett and Emma Plunkett describe in this article. -
Content Article
Flight Safety Foundation: Just Culture Manifesto
Patient Safety Learning posted an article in Culture
“Just Culture” is a culture in which front-line operators and others are not punished for actions, omissions or decisions taken by them which are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated. Organisations are run by people. In tens of industries – transportation, healthcare, energy, internet, and more – thousands of occupations, and millions of organisations around the world, it is people who make sure that things normally go well. And they nearly always do. But sometimes, things go wrong. Despite our best efforts, incidents, accidents and other unwanted events happen. Following such events, there is a need for support and fairness for those involved and affected, and learning for organisations, industry and society as whole. In the absence of intentional wrongdoing or gross negligence, these obligations should not be threatened by adverse responses either by organisations or States. The Flight Safety Foundation outline their Just Culture Manifesto and invite all who support the principles in this Manifesto to join them, and to help make Just Culture a reality in all countries, industries, and occupations. -
Content ArticleHuman performance is cited as a causal factor in the majority of aircraft accidents. This manual addressed various aspects of Human Factors and its impact on flight safety but many of the principles will be relevant to healthcare also.
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Content ArticleThis is the final report of the accident on 1 June 2009 to the Airbus A330-203 registered F-GZCP operated by Air France flight AF 447 Rio de Janeiro - Paris. The investigation was carried out by the BEA, the French Civil Aviation Safety Investigation Authority.
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Content ArticleThe theme of this Issue of Hindsight is ‘Wellbeing’, which has an undeniable link to safe operations, though this is not often spoken about. This Issue coincides with the COVID-19 pandemic. The authors of the articles in this Issue were considering wellbeing in the context of aviation, and other industries. But the articles touch on topics that are deeply relevant to the pandemic. The spread of the virus and its effect on our everyday lives has brought the biological, psychological, social, environmental, and economic aspects of wellbeing into clear view in a way we have never seen before.
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Content ArticleRecently, there has been a lot of interest in some ideas proposed by Prof. Erik Hollnagel and labeled as “Safety-II” and argued to be the basis for achieving system resilience. He contrasts Safety-II to what he describes as Safety-I, which he claims to be what engineers do now to prevent accidents. What he describes as Safety-I, however, has very little or no resemblance to what is done today or to what has been done in safety engineering for at least 70 years. In this paper, Prof. Nancy Leveson, Aeronautics and Astronautics Dept., MIT, describes the history of safety engineering, provides a description of safety engineering as actually practiced in different industries, shows the flaws and inaccuracies in Prof. Hollnagel’s arguments and the flaws in the Safety-II concept, and suggests that a systems approach (Safety-III) is a way forward for the future.
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Content ArticleThreat and Error Management (TEM) is an overarching safety concept regarding aviation operations and human performance. TEM is not a revolutionary concept, but one that has evolved gradually, as a consequence of the constant drive to improve the margins of safety in aviation operations through the practical integration of Human Factors knowledge. TEM was developed as a product of collective aviation industry experience. Such experience fostered the recognition that past studies and, most importantly, operational consideration of human performance in aviation had largely overlooked the most important factor influencing human performance in dynamic work environments: the interaction between people and the operational context (i.e., organisational, regulatory and environmental factors) within which people discharged their operational duties. This article gives the background to TEM, components of the TEM Framework, related articles and further reading.
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Content ArticleThis article, published by Forbes, looks at the airline industry and discusses the value in not only studying what pilots do wrong, but also what they do right. This can be translated into healthcare, we know lots about what has gone wrong in healthcare but not so much about the small, quiet things that go right. 'In aviation safety, it’s like we’ve been trying to learn about marriage by only studying divorce.' Written by Kirsty Kiernan a professor at Embry-Riddle Aeronautical University who teaches and conducts research in unmanned systems and aviation safety.
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Content ArticleIn many safety-critical environments, including healthcare, operators need to remember to perform a deferred task, which requires prospective memory. Laboratory experiments suggest that extended prospective memory retention intervals, and interruptions in those retention intervals, could impair prospective memory performance.
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Content ArticleTo find out how checklists and monitoring work in actual practice, Benjamin and Dismukes observed line operations during 60 flights conducted by three air carriers from two countries. They used a structured technique to observe and record checklist and monitoring performance, and situational factors that might affect performance. Because an important function of checklists and monitoring is to catch, or “trap,” operational errors, they also recorded deviations in aircraft control, navigation, communication and planning. When a deviation was observed, they tracked whether crewmembers identified and corrected it, and whether there were any consequences that might affect the outcome of the flight. They found that checklists and monitoring are not as effective as generally assumed.
