- Email: [email protected]
Re: Learning from Errors. Applying Aviation Safety Concepts to Medicine
EUROPEAN UROLOGY 64 (2013) 680–686
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Words of Wisdom Re: Learning from Errors. Applying Aviation Safety Concepts to Medicine Sommer KJ Urologe A 2012;51:1533–40 Expert’s summary: The author is a fully qualified airline pilot and certified Boeing 747 instructor. In addition, he has studied medicine and participated in orthopaedic surgery. He is the owner of a consulting firm (SMACmed) that specialises in transferring aviation safety concepts to health care. Based on the statement that health care safety levels range below other complex industries, he explains the key methods and concepts that have made the airplane into one of the safest means of mass transportation. Key elements include accident investigations focussing on cause instead of blame, human-centred design of machinery and processes, continuous training of all personnel, and a shared safety culture. The author argues that all these methods and concepts are basically applicable to medicine and have already has been achieved in certain areas (ie, a team time-out procedure prior to surgery). However, comprehensive implementation remains to be completed. This applies particularly to including the topic of safety in relevant curricula. Physicians are obliged by the oath primum nil nocere to act, but economic and political pressure will eventually confine professional freedom if the initiative is not taken soon. Expert’s comments: The tendency to err is intrinsic to biologic human behaviour and performance. It is impossible to eliminate errors completely from medical practice or to predict the moment of occurrence [1]. Among the errors resulting in death in hospitals, the surgical ones account for the most [2]. Urology, with a high caseload of minimally invasive surgery (MIS), is one of the three specialities, together with general surgery and gynaecology, in which endoscopic surgical errors have been critically analysed by third parties and institutional safety measures have been advised for training and recertification during one’s professional career [2,3]. However, even including new activities in a more standardised reporting and classification of complications [4], the classification of surgical errors remains confusing. Error is an unintended health care outcome by defect in the delivery of care to a patient. Surgical errors are common and account for half of all hospital-related adverse events. 0302-2838/$ – see back matter
Urology is the fifth speciality in decreasing order of adverse events. Errors may be classified according to the place where they occur (co-face or systemic) and to the outcomes (near miss, recovery, and remediation). Co-face errors are active errors, specific to surgical performance, and they can be subdivided into input errors (of knowledge and perception), intention errors (mind-set), and execution errors (psychomotor). Systemic errors consist of an unfortunate chain of wrong commissions, omissions, or executions. They are subdivided into coherence and goal conflicts, poor leadership, inadequate teamwork, inadequate training, inadequate resource allocation, unclear protocols or briefings, lack of evidence-based practice, and overwork [2]. In essence, any surgical error lies between these two classes (co-face or systemic), even if a substantial proportion of responsibility lies exclusively in the hands of the surgeon. There have been attempts in surgery and particularly in MIS to minimise both the person and the factual error by implementing safe surgical components including strategic control of health care delivery, harmonious teamwork, effective leadership, application of evidence-based medicine, surgical proficiency, continuous professional development of all staff, easy access to health care information technology, and well-embedded incident reporting [1,2]. So what can we learn from aviation? I am convinced there is a lot for urologists to learn. Whereas we are just starting to understand the theory of error development, the International Air Transport Association (IATA) collects all incidents, including near misses, based on a punishmentfree reporting system: 36% are human related; 26%, environmental; 25%, organisational; and 13%, technical. Human-related errors/near misses are calculated as based on active failure (37%), lack of expertise (34%), and passive failure (29%). The overall accident rate in aviation is 0.37 per 1 million flights. IATA uses a standardised classification of accidents in 4 main categories and 34 subcategories. One of the key elements in aviation is accident evaluation focussing on cause rather than blame. In surgery, there is still the tendency to ask who committed the error and not why it happened. If we want to get realistic figures about the incidence of near misses to develop measures of prevention, we have to install an anonymous reporting system like the IATA model.
681
EUROPEAN UROLOGY 64 (2013) 680–686
Most interestingly for surgeons is the classification of pilot personality and its relationship to the risk of committing an error, distinguishing among five hazard thought patterns: the invulnerable (‘‘It will always work’’), the macho (‘‘I am the only one who can do it’’), the impulsive (‘‘We must do something—now’’), the antiauthority (‘‘I am not one to be regulated like this’’), and the resignation type (‘‘We cannot change the situation anyway’’). A questionnaire has been developed describing specific scenarios to enable the pilot to better understand the risk profile based on his or her personality [5,6]. Such a system might be very helpful for surgeons. In addition, we have to improve the teamwork flattening the hierarchic structures in our operating theatres. In aviation, this is accomplished using crew resource management with hardware, software, and ‘‘lifeware’’ for safe and efficient operation. In aviation, a standardised training programme based on simulators includes semiannual reevaluation. On the simulator the entire team is checked. In urology, there are a variety of training programs mainly focussing on laparoscopic or endourologic procedures with low- and high-fidelity simulators [7,8]. However, there is no curriculum that demands and evaluates the performance of trainees and even experienced surgeons. In surgery, we are still used to the master–scholar relationship to learn a procedure at bedside rather than using simulators. The quality of simulators for surgical procedures are still far away from a flight simulator, but there are models used in pelvic trainers with and without organ perfusion that have proven different levels of validity [7–9]. Another key element in aviation is checklists. The use of checklists and standard operative procedures (SOPs) has significantly increased in medicine in the last decade. In most operating rooms today, the time-out procedure prior to surgery and checking the names of the actors (anaesthetist, surgeon, and staff), the identity of the patient, and
Re: Strategy for Detection of Prostate Cancer Based on Relation Between Prostate Specific Antigen at Age 40-55 and Long Term Risk of Metastasis: Case-control Study Vickers AJ, Ulmert D, Sjoberg DD, et al. BMJ 2013;346:f2023 Experts’ summary: This is one of the breakthrough papers suggesting riskadapted prostate-specific antigen (PSA) screening based on an early PSA value in men 45–49 yr of age. PSA values of 21 277 Swedish men provided by blood samples drawn from 1974 to 1984 were correlated to metastasis or death from prostate cancer (PCa) about 30–40 yr later. Overall, 44% of the deaths from PCa occurred in patients with baseline values in the upper 10% of the cohort (>1.6 ng/ml). The risk of metastasis 15 yr later in this young cohort was only 0.09% if the baseline PSA was below the median (0.68 ng/ml). Three
the type and localisation of the disease has become an SOP. This will have an impact on the safety of our surgical procedures. Conflicts of interest: The author has nothing to disclose.
References [1] Cuschieri A. Medical errors, incidents, accidents and violations. Minim Invasive Ther Allied Technol 2003;12:111–20. [2] Rassweiler MC, Mamoulakis C, Kenngott HG, Rassweiler J, de la Rosette J, Laguna MP. Classification and detection of errors in minimally invasive surgery. J Endourol 2011;25:1713–21. [3] Satava RM. Identification and reduction of surgical error using simulation. Minim Invasive Ther Allied Technol 2005;14:257–61. [4] Mitropoulos D, Artibani W, Graefen M, Remzi M, Roupreˆt M, Truss M. Reporting and grading of complications after urologic surgical procedures: an ad hoc EAU guidelines panel assessment and recommendations. Eur Urol 2012;61:341–9. [5] Reason J. Human error. Models and management. BMJ 2000;320: 768–70. [6] Molesworth BR, Chang B. Predicting pilots’ risk-taking behavior through an implicit association test. Hum Factors 2009;51:845–57. [7] Klein J, Teber D, Frede T, et al. Development, validation and operating room-transfer of a six-step laparoscopic training program for the vesicourethral anastomosis. J Endourol 2013;27:349–54. [8] Rassweiler J, Klein J, Teber D, Schulze M, Frede T. Mechanical simulators for training for laparoscopic surgery in urology. J Endourol 2007;21:252–62. [9] Erdogru T, Yucel S, Frede T, Baykara M, Rassweiler J, Teber D. Laparoscopic radical prostatectomy: transfer validity. Int J Urol 2010;17: 476–82.
Jens Jochen Rassweiler Department of Urology, SLK Klinken Heilbronn, Heilbronn, Germany E-mail address: [email protected]. http://dx.doi.org/10.1016/j.eururo.2013.07.014
lifetime PSA values below the age median at 40, 50, and 60 yr of age may be sufficient to rule out death from PCa for about half of men. Experts’ comments: This is the largest retrospective database correlating PSA values from more than three decades ago with metastasis or death from PCa. The results provide the scientific basis to use a baseline PSA value for risk assessment in young men (45–49 yr of age). The authors showed previously that PSA screening can be stopped at 60 yr of age if PSA is <1 ng/ml [1]. This paper extends that knowledge and now recommends a first PSA value at age 45–49 yr, since it is predictive of death if confirmed twice until the patient is 60 yr of age. The paper provides very useful information, but the design of the study has some limitations. First, as in all screening studies, the absolute number of patients dying from PCa is small. In a Consolidated Standards of Reporting Trials table, the initial 21 277 men with a baseline PSA at
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Words of Wisdom Re: Learning from Errors. Applying Aviation Safety Concepts to Medicine Sommer KJ Urologe A 2012;51:1533–40 Expert’s summary: The author is a fully qualified airline pilot and certified Boeing 747 instructor. In addition, he has studied medicine and participated in orthopaedic surgery. He is the owner of a consulting firm (SMACmed) that specialises in transferring aviation safety concepts to health care. Based on the statement that health care safety levels range below other complex industries, he explains the key methods and concepts that have made the airplane into one of the safest means of mass transportation. Key elements include accident investigations focussing on cause instead of blame, human-centred design of machinery and processes, continuous training of all personnel, and a shared safety culture. The author argues that all these methods and concepts are basically applicable to medicine and have already has been achieved in certain areas (ie, a team time-out procedure prior to surgery). However, comprehensive implementation remains to be completed. This applies particularly to including the topic of safety in relevant curricula. Physicians are obliged by the oath primum nil nocere to act, but economic and political pressure will eventually confine professional freedom if the initiative is not taken soon. Expert’s comments: The tendency to err is intrinsic to biologic human behaviour and performance. It is impossible to eliminate errors completely from medical practice or to predict the moment of occurrence [1]. Among the errors resulting in death in hospitals, the surgical ones account for the most [2]. Urology, with a high caseload of minimally invasive surgery (MIS), is one of the three specialities, together with general surgery and gynaecology, in which endoscopic surgical errors have been critically analysed by third parties and institutional safety measures have been advised for training and recertification during one’s professional career [2,3]. However, even including new activities in a more standardised reporting and classification of complications [4], the classification of surgical errors remains confusing. Error is an unintended health care outcome by defect in the delivery of care to a patient. Surgical errors are common and account for half of all hospital-related adverse events. 0302-2838/$ – see back matter
Urology is the fifth speciality in decreasing order of adverse events. Errors may be classified according to the place where they occur (co-face or systemic) and to the outcomes (near miss, recovery, and remediation). Co-face errors are active errors, specific to surgical performance, and they can be subdivided into input errors (of knowledge and perception), intention errors (mind-set), and execution errors (psychomotor). Systemic errors consist of an unfortunate chain of wrong commissions, omissions, or executions. They are subdivided into coherence and goal conflicts, poor leadership, inadequate teamwork, inadequate training, inadequate resource allocation, unclear protocols or briefings, lack of evidence-based practice, and overwork [2]. In essence, any surgical error lies between these two classes (co-face or systemic), even if a substantial proportion of responsibility lies exclusively in the hands of the surgeon. There have been attempts in surgery and particularly in MIS to minimise both the person and the factual error by implementing safe surgical components including strategic control of health care delivery, harmonious teamwork, effective leadership, application of evidence-based medicine, surgical proficiency, continuous professional development of all staff, easy access to health care information technology, and well-embedded incident reporting [1,2]. So what can we learn from aviation? I am convinced there is a lot for urologists to learn. Whereas we are just starting to understand the theory of error development, the International Air Transport Association (IATA) collects all incidents, including near misses, based on a punishmentfree reporting system: 36% are human related; 26%, environmental; 25%, organisational; and 13%, technical. Human-related errors/near misses are calculated as based on active failure (37%), lack of expertise (34%), and passive failure (29%). The overall accident rate in aviation is 0.37 per 1 million flights. IATA uses a standardised classification of accidents in 4 main categories and 34 subcategories. One of the key elements in aviation is accident evaluation focussing on cause rather than blame. In surgery, there is still the tendency to ask who committed the error and not why it happened. If we want to get realistic figures about the incidence of near misses to develop measures of prevention, we have to install an anonymous reporting system like the IATA model.
681
EUROPEAN UROLOGY 64 (2013) 680–686
Most interestingly for surgeons is the classification of pilot personality and its relationship to the risk of committing an error, distinguishing among five hazard thought patterns: the invulnerable (‘‘It will always work’’), the macho (‘‘I am the only one who can do it’’), the impulsive (‘‘We must do something—now’’), the antiauthority (‘‘I am not one to be regulated like this’’), and the resignation type (‘‘We cannot change the situation anyway’’). A questionnaire has been developed describing specific scenarios to enable the pilot to better understand the risk profile based on his or her personality [5,6]. Such a system might be very helpful for surgeons. In addition, we have to improve the teamwork flattening the hierarchic structures in our operating theatres. In aviation, this is accomplished using crew resource management with hardware, software, and ‘‘lifeware’’ for safe and efficient operation. In aviation, a standardised training programme based on simulators includes semiannual reevaluation. On the simulator the entire team is checked. In urology, there are a variety of training programs mainly focussing on laparoscopic or endourologic procedures with low- and high-fidelity simulators [7,8]. However, there is no curriculum that demands and evaluates the performance of trainees and even experienced surgeons. In surgery, we are still used to the master–scholar relationship to learn a procedure at bedside rather than using simulators. The quality of simulators for surgical procedures are still far away from a flight simulator, but there are models used in pelvic trainers with and without organ perfusion that have proven different levels of validity [7–9]. Another key element in aviation is checklists. The use of checklists and standard operative procedures (SOPs) has significantly increased in medicine in the last decade. In most operating rooms today, the time-out procedure prior to surgery and checking the names of the actors (anaesthetist, surgeon, and staff), the identity of the patient, and
Re: Strategy for Detection of Prostate Cancer Based on Relation Between Prostate Specific Antigen at Age 40-55 and Long Term Risk of Metastasis: Case-control Study Vickers AJ, Ulmert D, Sjoberg DD, et al. BMJ 2013;346:f2023 Experts’ summary: This is one of the breakthrough papers suggesting riskadapted prostate-specific antigen (PSA) screening based on an early PSA value in men 45–49 yr of age. PSA values of 21 277 Swedish men provided by blood samples drawn from 1974 to 1984 were correlated to metastasis or death from prostate cancer (PCa) about 30–40 yr later. Overall, 44% of the deaths from PCa occurred in patients with baseline values in the upper 10% of the cohort (>1.6 ng/ml). The risk of metastasis 15 yr later in this young cohort was only 0.09% if the baseline PSA was below the median (0.68 ng/ml). Three
the type and localisation of the disease has become an SOP. This will have an impact on the safety of our surgical procedures. Conflicts of interest: The author has nothing to disclose.
References [1] Cuschieri A. Medical errors, incidents, accidents and violations. Minim Invasive Ther Allied Technol 2003;12:111–20. [2] Rassweiler MC, Mamoulakis C, Kenngott HG, Rassweiler J, de la Rosette J, Laguna MP. Classification and detection of errors in minimally invasive surgery. J Endourol 2011;25:1713–21. [3] Satava RM. Identification and reduction of surgical error using simulation. Minim Invasive Ther Allied Technol 2005;14:257–61. [4] Mitropoulos D, Artibani W, Graefen M, Remzi M, Roupreˆt M, Truss M. Reporting and grading of complications after urologic surgical procedures: an ad hoc EAU guidelines panel assessment and recommendations. Eur Urol 2012;61:341–9. [5] Reason J. Human error. Models and management. BMJ 2000;320: 768–70. [6] Molesworth BR, Chang B. Predicting pilots’ risk-taking behavior through an implicit association test. Hum Factors 2009;51:845–57. [7] Klein J, Teber D, Frede T, et al. Development, validation and operating room-transfer of a six-step laparoscopic training program for the vesicourethral anastomosis. J Endourol 2013;27:349–54. [8] Rassweiler J, Klein J, Teber D, Schulze M, Frede T. Mechanical simulators for training for laparoscopic surgery in urology. J Endourol 2007;21:252–62. [9] Erdogru T, Yucel S, Frede T, Baykara M, Rassweiler J, Teber D. Laparoscopic radical prostatectomy: transfer validity. Int J Urol 2010;17: 476–82.
Jens Jochen Rassweiler Department of Urology, SLK Klinken Heilbronn, Heilbronn, Germany E-mail address: [email protected]. http://dx.doi.org/10.1016/j.eururo.2013.07.014
lifetime PSA values below the age median at 40, 50, and 60 yr of age may be sufficient to rule out death from PCa for about half of men. Experts’ comments: This is the largest retrospective database correlating PSA values from more than three decades ago with metastasis or death from PCa. The results provide the scientific basis to use a baseline PSA value for risk assessment in young men (45–49 yr of age). The authors showed previously that PSA screening can be stopped at 60 yr of age if PSA is <1 ng/ml [1]. This paper extends that knowledge and now recommends a first PSA value at age 45–49 yr, since it is predictive of death if confirmed twice until the patient is 60 yr of age. The paper provides very useful information, but the design of the study has some limitations. First, as in all screening studies, the absolute number of patients dying from PCa is small. In a Consolidated Standards of Reporting Trials table, the initial 21 277 men with a baseline PSA at