On error management: lessons from aviation

On error management: lessons from aviation

18 MARCH 2000 | Robert L Helmreich
The article discusses the application of aviation's error management strategies to improve patient safety in medical settings, particularly in operating rooms. It highlights the importance of understanding and addressing human error, which is a common cause of adverse events in healthcare. The authors emphasize the need for standardized methods of investigation, documentation, and dissemination of errors, as well as the development of comprehensive training programs to enhance teamwork and communication. They also introduce a model for identifying and managing threats and errors, which includes factors such as fatigue, workload, and cognitive overload. The article provides a case study to illustrate how this model can be applied to identify and address sequential errors and latent organizational threats. Finally, it outlines a six-step approach for establishing effective error management programs in healthcare organizations, emphasizing the importance of data-driven actions and continuous improvement.The article discusses the application of aviation's error management strategies to improve patient safety in medical settings, particularly in operating rooms. It highlights the importance of understanding and addressing human error, which is a common cause of adverse events in healthcare. The authors emphasize the need for standardized methods of investigation, documentation, and dissemination of errors, as well as the development of comprehensive training programs to enhance teamwork and communication. They also introduce a model for identifying and managing threats and errors, which includes factors such as fatigue, workload, and cognitive overload. The article provides a case study to illustrate how this model can be applied to identify and address sequential errors and latent organizational threats. Finally, it outlines a six-step approach for establishing effective error management programs in healthcare organizations, emphasizing the importance of data-driven actions and continuous improvement.
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