As aircraft have become more reliable, humans have played a progressively more important causal role in aviation accidents. Consequently, a growing number of aviation organizations are tasking their ...safety personnel with developing accident investigation and other safety programs to address the highly complex and often nebulous issue of human error. Yet, many safety professionals are illequipped to perform these new duties.
The purpose of the present book is to remedy this situation by presenting a comprehensive, userfriendly framework to assist practitioners in effectively investigating and analyzing human error in aviation. Coined the Human Factors Analysis and Classification System (HFACS), its framework is based on James Reason's (1990) well-known "Swiss cheese" model of accident causation. In essence, HFACS bridges the gap between theory and practice in a way that helps improve both the quantity and quality of information gathered in aviation accidents and incidents.
The HFACS framework was originally developed for, and subsequently adopted by, the U.S. Navy/Marine Corps as an accident investigation and data analysis tool. The U.S. Army, Air Force, and Coast Guard, as well as other military and civilian aviation organizations around the world are also currently using HFACS to supplement their preexisting accident investigation systems. In addition, HFACS has been taught to literally thousands of students and safety professionals through workshops and courses offered at professional meetings and universities. Indeed, HFACS is now relatively well known within many sectors of aviation and an increasing number of organizations worldwide are interested in exploring its usage. Consequently, the authors currently receive numerous requests for more information about the system on what often seems to be a daily basis.
Background Disruptions in surgical flow have the potential to increase the occurrence of surgical errors; however, little is known about the frequency and nature of surgical flow disruptions and ...their effect on the etiology of errors, which makes the development of evidence-based interventions extremely difficult. The goal of this project was to study surgical errors and their relationship to surgical flow disruptions in cardiovascular surgery prospectively to understand better the effect of these disruptions on surgical errors and ultimately patient safety. Methods A trained observer recorded surgical errors and flow disruptions during 31 cardiac surgery operations over a 3-week period and categorized them by a classification system of human factors. Flow disruptions were then reviewed and analyzed by an interdisciplinary team of experts in operative and human factors. Results Flow disruptions consisted of teamwork/communication failures, equipment and technology problems, extraneous interruptions, training-related distractions, and issues in resource accessibility. Surgical errors increased significantly with increases in flow disruptions. Teamwork/communication failures were the strongest predictor of surgical errors. Conclusion These findings provide preliminary data to develop evidenced-based error management and patient safety programs within cardiac surgery with implications to other related surgical programs.
Efforts to implement quality improvements in surgery are notoriously problematic. One needs to look no farther than recent attempts to implement checklists, team training, and surgical briefings. ...These interventions have been empirically shown to improve team communication and performance. Yet numerous barriers to implementation have limited their broad adoption and use. Apparently, knowing the remedy (intervention) does not translate into knowing how to administer (implement) it. Or in surgical terms, knowing "what" procedure needs to be performed does not necessarily mean that one knows "how" to perform it. Surgeons serve a vital leadership role in driving quality and patient safety initiatives in the operating room. Achieving success requires both an in-depth understanding of the intervention and the complex dynamics of the elements involved in the implementation process. To aid in this endeavor, the present article describes a Model for Understanding System Transitions Associated with the Implementation of New Goals (MUSTAING). The model highlights important variables associated with implementation success. It also provides a tool for diagnosing why certain interventions may not have worked as intended so that improvements in the implementation process can be made. Finally, the model offers a general framework for guiding future implementation or "how to" research.
We sought to develop and evaluate a video-based coaching program for board-eligible/certified surgeons.
Multiple disciplines utilize coaching for continuous professional development; however, ...coaching is not routinely employed for practicing surgeons.
Peer-nominated surgeons were trained as coaches then paired with participant surgeons. After setting goals, each coaching pair reviewed video-recorded operations performed by the participating surgeon. Coaching sessions were audio-recorded, transcribed, and coded to identify topics discussed. The effectiveness with which our coaches were able to utilize the core principles and activities of coaching was evaluated using 3 different approaches: self-evaluation; evaluation by the participants; and assessment by the study team. Surveys of participating surgeons and coach-targeted interviews provided general feedback on the program. All measures utilized a 5-point Likert scale format ranging from 1 (low) to 5 (high).
Coach-participant surgeon pairs targeted technical, cognitive, and interpersonal aspects of performance. Other topics included managing intraoperative stress. Mean objective ratings of coach effectiveness was 3.1 ± 0.7, ranging from 2.0 to 5.0 on specific activities of coaching. Subjective ratings by coaches and participants were consistently higher. Coaches reported that the training provided effectively prepared them to facilitate coaching sessions. Participants were similarly positive about interactions with their coaches. Identified barriers were related to audio-video technology and scheduling of sessions. Overall, participants were satisfied with their experience (mean 4.4 ± 0.7) and found the coaching program valuable (mean 4.7 ± 0.7).
This is the first report of cross-institutional surgical coaching for the continuous professional development of practicing surgeons, demonstrating perceived value among participants, as well as logistical challenges for implementing this evidence-based program. Future research is necessary to evaluate the impact of coaching on practice change and patient outcomes.
Abstract
Background
Many patient safety organizations recommend the use of the action hierarchy (AH) to identify strong corrective actions following an investigative analysis of patient harm events. ...Strong corrective actions, such as forcing functions and equipment standardization, improve patient safety by either preventing the occurrence of active failures (i.e. errors or violations) or reducing their consequences if they do occur.
Problem
We propose that the emphasis on implementing strong fixes that incrementally improve safety one event at a time is necessary, yet insufficient, for improving safety. This singular focus has detracted from the pursuit of major changes that transform systems safety by targeting the latent conditions which consistently underlie active failures. To date, however, there are no standardized models or methods that enable patient safety professionals to assess, develop and implement systems changes to improve patient safety.
Approach
We propose a multifaceted definition of ‘systems change’. Based on this definition, various types and levels of systems change are described. A rubric for determining the extent to which a specific corrective action reflects a ‘systems change’ is provided. This rubric incorporates four fundamental dimensions of systems change: scope, breadth, depth and degree. Scores along these dimensions can then be used to classify corrective actions within our proposed systems change hierarchy (SCH).
Conclusion
Additional research is needed to validate the proposed rubric and SCH. However, when used in conjunction with the AH, the SCH perspective will serve to foster a more holistic and transformative approach to patient safety.
Objective: The aim of this study was to extend previous examinations of aviation accidents to include specific aircrew, environmental, supervisory, and organizational factors associated with two ...types of commercial aviation (air carrier and commuter/ on-demand) accidents using the Human Factors Analysis and Classification System (HFACS). Background: HFACS is a theoretically based tool for investigating and analyzing human error associated with accidents and incidents. Previous research has shown that HFACS can be reliably used to identify human factors trends associated with military and general aviation accidents. Method: Using data obtained from both the National Transportation Safety Board and the Federal Aviation Administration, 6 pilot-raters classified aircrew, supervisory, organizational, and environmental causal factors associated with 1020 commercial aviation accidents that occurred over a 13-year period. Results: The majority of accident causal factors were attributed to aircrew and the environment, with decidedly fewer associated with supervisory and organizational causes. Comparisons were made between HFACS causal categories and traditional situational variables such as visual conditions, injury severity, and regional differences. Conclusion: These data will provide support for the continuation, modification, and/or development of interventions aimed at commercial aviation safety. Application: HFACS provides a tool for assessing human factors associated with accidents and incidents.
Background
Postcancer work limitations may affect a substantial proportion of patients and contribute to the “financial toxicity” of cancer treatment. The degree and nature of work limitations and ...employment outcomes are poorly understood for cancer patients, particularly in the immediate period of transition after active treatment. We prospectively examined employment, work ability, and work limitations during and after treatment.
Methods
A total of 120 patients receiving curative therapy who were employed prior to their cancer diagnosis and who intended to work during or after end of treatment (EOT) completed surveys at baseline (pretreatment), EOT, and 3, 6, and 12 months after EOT. Surveys included measures of employment, work ability, and work limitations. Descriptive statistics (frequencies, percentages, means with standard deviations) were calculated.
Results
A total of 111 participants completed the baseline survey. On average, participants were 48 years of age and were mostly white (95%) and female (82%) with a diagnosis of breast cancer (69%). Full‐time employment decreased during therapy (from 88% to 50%) and returned to near prediagnosis levels by 12‐month follow‐up (78%). Work‐related productivity loss due to health was high during treatment.
Conclusions
This study is the first to report the effects of curative intent cancer therapy on employment, work ability, and work limitations both during and after treatment. Perceived work ability was generally high overall 12 months after EOT, although a minority reported persistent difficulty. A prospective analysis of factors (eg, job type, education, symptoms) most associated with work limitations is underway to assist in identifying at‐risk patients.
Adjuvant therapy for cancer can have a negative effect on a patient's ability to work, but the degree of work limitation due to cancer treatment has not been captured prospectively in a longitudinal fashion. This prospective study of patients with cancer receiving adjuvant chemotherapy who worked during cancer treatment reveals that most patients eventually returned to the same level of work that they had performed before treatment.
This article reviews several key aspects of the Theory of Active and Latent Failures, typically referred to as the Swiss cheese model of human error and accident causation. Although the Swiss cheese ...model has become well known in most safety circles, there are several aspects of its underlying theory that are often misunderstood. Some authors have dismissed the Swiss cheese model as an oversimplification of how accidents occur, whereas others have attempted to modify the model to make it better equipped to deal with the complexity of human error in health care. This narrative review aims to provide readers with a better understanding and greater appreciation of the Theory of Active and Latent Failures upon which the Swiss cheese model is based. The goal is to help patient safety professionals fully leverage the model and its associated tools when performing a root cause analysis as well as other patient safety activities.
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