Research Article | Open Access
Learning from Aviation to Improve Safety in the Operating Room - a Systematic Literature Review
Lessons learned from other high-risk industries could improve patient safety in the operating room (OR). This review describes similarities and differences between high-risk industries and describes current methods and solutions within a system approach to reduce errors in the OR. PubMed and Scopus databases were systematically searched for relevant articles written in the English language published between 2000 and 2011. In total, 25 articles were included, all within the medical domain focusing on the comparison between surgery and aviation. In order to improve safety in the OR, multiple interventions have to be implemented. Additionally, the healthcare organization has to become a ‘learning organization’ and the OR team has to become a team with shared responsibilities and flat hierarchies. Interpersonal and technical skills can be trained by means of simulation and can be supported by implementing team briefings, debriefings and cross-checks. However, further development and research is needed to prove if these solutions are useful, practical, and actually increase safety.
- E. G. Verdaasdonk, L. P. Stassen, p. p. Widhiasmara, and J. Dankelman, “Requirements for the design and implementation of checklists for surgical processes,” Surg Endosc, vol. 23, no. 4, pp. 715–726, 2009.
- N. Sevdalis, R. Davis, M. Koutantji, S. Undre, A. Darzi, and C. A. Vincent, “Reliability of a revised NOTECHS scale for use in surgical teams,” Am J Surg, vol. 196, no. 2, pp. 184–190, 2008.
- S. Olsen, S. Undre, and C. Vincent, “Safety in surgery: First steps towards a systems approach,” Clinical Risk, vol. 11, no. 5, pp. 190–194, 2005.
- S. Undre, S. Arora, and N. Sevdalis, “Surgical performance, human error and patient safety in urological surgery,” British Journal of Medical and Surgical Urology, vol. 2, no. 1, pp. 2–10, 2009.
- C. Vincent, K. Moorthy, S. K. Sarker, A. Chang, and A. W. Darzi, “Systems approaches to surgical quality and safety: from concept to measurement.,” Ann Surg, vol. 239, no. 4, pp. 475–482, 2004.
- J. F. Calland, S. Guerlain, R. B. Adams, C. G. Tribble, E. Foley, and E. G. Chekan, “A systems approach to surgical safety,” Surg Endosc, vol. 16, no. 6, pp. 1005–1014, discussion 1015, 2002.
- L. T. Kohn, J. M. Corrigan, and M. S. Donaldson, To Err is Human: Building a safer health system, National Academy Press, Washington DC, 2000.
- L. La Pietra, L. Calligaris, L. Molendini, R. Quattrin, and S. Brusaferro, “Medical errors and clinical risk management: state of the art,” Acta Otorhinolaryngol. Ital, vol. 25, no. 6, pp. 339–346, 2005.
- J. Reason, “Human error: models and management,” BMJ, vol. 320, no. 7237, pp. 768–770, 2000.
- K. R. Catchpole, A. E. Giddings, M. R. de Leval et al., “Identification of systems failures in successful paediatric cardiac surgery,” Ergonomics, vol. 49, no. 5–6, pp. 567–588, 2006.
- J. Dankelman and C. A. Grimbergen, “Systems approach to reduce errors in surgery,” Surg Endosc, vol. 19, no. 8, pp. 1017–1021, 2005.
- A. Cuschieri, “Nature of Human Error. Implications for Surgical Practice,” Ann. Surg, vol. 244, no. 5, pp. 642–648, 2006.
- M. Wentink, L. P. S. Stassen, I. Alwayn, R. J. A. W. Hosman, and H. G. Stassen, “Rasmussen's model of human behavior in laparoscopy training,” Surgical Endoscopy, vol. 17(-), pp. 1241–1246, 2003.
- A. Mishra, K. Catchpole, T. Dale, and P. McCulloch, “The influence of non-technical performance on technical outcome in laparoscopic cholecystectomy,” Surg Endosc, vol. 22, no. 1, pp. 68–73, 2008.
- B. D. Dotan, “Patient safety organizations: A new paradigm in quality management and communication systems in healthcare,” J. Clin. Eng, vol. 34, no. 3, pp. 142–146, 2009.
- J. B. Sexton, E. J. Thomas, and R. L. Helmreich, “stress, and teamwork in medicine and aviation: cross sectional surveys,” BMJ, vol. 320, no. 7237, pp. 745–749, 2000.
- R. L. Helmreich, “On error management: lessons from aviation,” BMJ, vol. 320, no. 7237, pp. 781–785, 2000.
- R. Aggarwal, S. Undre, K. Moorthy, C. Vincent, and A. Darzi, “The simulated operating theatre: comprehensive training for surgical teams,” Quality & safety in health care, vol. 13 (Suppl 1), pp. i27–32, 2004.
- S. Arora and N. Sevdalis, “Systems Approach to daily clinical care,” Int J Surg, vol. 8, no. 2, pp. 164–166, 2010.
- J. Benn, M. Koutantji, L. Wallace et al., “Feedback from incident reporting: information and action to improve patient safety,” Quality & safety in health care, vol. 18, no. 1, pp. 11–21, 2009.
- P. J. Fabri and J. L. Zayas-Castro, “Human error, not communication and systems, underlies surgical complications,” Surgery, vol. 144, no. 4, pp. 557–563, 2008.
- T. B. Hugh, “New strategies to prevent laparoscopic bile duct injury—surgeons can learn from pilots,” Surgery, vol. 132, no. 5, pp. 826–835, 2002.
- K. Moorthy, Y. Munz, S. Adams, V. Pandey, and A. A. Darzi, “human factors analysis of technical and team skills among surgical trainees during procedural simulations in a simulated operating theatre,” Ann Surg, vol. 242, no. 5, pp. 631–639, 2005.
- K. Moorthy, Y. Munz, D. Forrest et al., “Surgical crisis management skills training and assessment: a simulation-based approach to enhancing operating room performance,” Ann Surg, vol. 244, no. 1, pp. 139–147, 2006.
- M. van Beuzekom, S. P. Akerboom, and F. Boer, “Assessing system failures in operating rooms and intensive care units,” Quality & safety in health care, vol. 16, no. 1, pp. 45–50, 2007.
- F. A. Drews and D. Fawcett, “Why healthcare is not like aviation: Control of natural and technical systems,” in Conf Proc 54th Human Factors and Ergonomics Society Annual Meeting 2010, HFES, vol. 1, pp. 369–373, 2010. Year.
- L. N. Nascimento and S. J. Calil, “The clinical data recorder: What shall be monitored?” in Conf Proc 12th Mediterranean Conference on Medical and Biological Engineering and Computing, MEDICON, vol. 29, pp. 995–998, 2010. Year.
- S. P. Rodrigues, A. M. Wever, J. Dankelman, and F. W. Jansen, “Risk factors in patient safety: minimally invasive surgery versus conventional surgery,” Surg Endosc, 2011.
- R. R. Thiagarajan, G. L. Bird, K. Harrington et al., “Improving safety for children with cardiac disease,” Cardiol. Young, vol. 17, Suppl 2, pp. 127–132, 2007.
- H. H. Lien, C. C. Huang, J. S. Liu et al., “System approach to prevent common bile duct injury and enhance performance of laparoscopic cholecystectomy,” Surg Laparosc Endosc Percutan Tech, vol. 17, no. 3, pp. 164–170, 2007.
- R. Wilf-Miron, I. Lewenhoff, Z. Benyamini, and A. Aviram, “From aviation to medicine: applying concepts of aviation safety to risk management in ambulatory care,” Quality & safety in health care, vol. 12, no. 1, pp. 35–39, 2003.
- T. W. Nolan, “System changes to improve patient safety,” BMJ, vol. 320, no. 7237, pp. 771–773, 2000.
- M. S. Joshi, J. F. Anderson, and S. Marwaha, “A systems approach to improving error reporting,” J. Healthc. Inf. Manag, vol. 16, no. 1, pp. 40–45, 2002.
- F. T. Durso and F. A. Drews, “Health care, aviation, and ecosystems: A socio-natural systems perspective,” Current Directions in Psychological Science, vol. 19, no. 2, pp. 71–75, 2010.
- M. Tamuz and E. J. Thomas, “Classifying and interpreting threats to patient safety in hospitals: Insights from aviation,” Journal of Organizational Behavior, vol. 27, no. 7, pp. 919–940, 2006.
- R. Amalberti, Y. Auroy, D. Berwick, and P. Barach, “Five system barriers to achieving ultrasafe health care,” Annals of internal medicine, vol. 142, no. 9, pp. 756–764, 2005.
- M. Muller, “Safety lessons taken from the airlines,” Br J Surg, vol. 91, no. 4, pp. 393–394, 2004.
- A. C. Edmondson, “Learning from failure in health care: frequent opportunities, pervasive barriers,” Quality & safety in health care, vol. 13, Suppl 2, pp. ii3–9, 2004.
- P. Carayon, A. Schoofs Hundt, B. T. Karsh et al., “Work system design for patient safety: the SEIPS model,” Quality & safety in health care, vol. 15, Suppl 1, pp. i50–58, 2006.
- A. B. Haynes, T. G. Weiser, W. R. Berry et al., “A surgical safety checklist to reduce morbidity and mortality in a global population,” N. Engl. J. Med, vol. 360, no. 5, pp. 491–499, 2009.
- C. M. Dekker-van Doorn, L. S. G. L. Wauben, B. Bonke et al., “Introducing TOPplus in the Operating Theatre,” in Safer Surgery–Analysing behaviour in the operating theatre, R. Flin and L. Mitchell, Eds., pp. 151–171, Ashgate, Farnham, 2009.
- World Health Organization, WHO Guidelines for Safe Surgery, first edition, 2008.
- E. G. Verdaasdonk, L. P. Stassen, W. F. Hoffmann, M. van der Elst, and J. Dankelman, “Can a structured checklist prevent problems with laparoscopic equipment,” Surg Endosc, vol. 22, no. 10, pp. 2238–2243, 2008.
- S. N. Buzink, L. van Lier, I. H. de Hingh, and J. J. Jakimowicz, “Risk-sensitive events during laparoscopic cholecystectomy: the influence of the integrated operating room and a preoperative checklist tool,” Surg Endosc, vol. 24, no. 8, pp. 1990–1995, 2010.
- E. N. de Vries, H. A. Prins, R. M. Crolla et al., “Effect of a comprehensive surgical safety system on patient outcomes,” N. Engl. J. Med, vol. 363, no. 20, pp. 1928–1937, 2010.
- T. Diamond and D. J. Mole, “Anatomical orientation and cross-checking-the key to safer laparoscopic cholecystectomy,” Br J Surg, vol. 92, no. 6, pp. 663–664, 2005.
- E. S. Patterson, D. D. Woods, R. I. Cook, and M. L. Render, “Collaborative cross-checking to enhance resilience,” Cognition, Technology & Work, vol. 9, no. 3, pp. 155–162, 2007.
- M. C. Pian-Smith, R. Simon, R. D. Minehart et al., “Teaching residents the two-challenge rule: a simulation-based approach to improve education and patient safety,” Simul Healthc, vol. 4, no. 2, pp. 84–91, 2009.
- Federal Aviation Administration, http://rgl.faa.gov, Accessed May 8, 2012.
- UK Civil Aviation Authority, http://www.caa.co.uk, Accessed May 8, 2012.
- National Transportation Safety Board, Introduction of Glass Cockpit Avionics Into Light Aircraft, 2010, http://www.ntsb.gov/safety/safetystudies/SS1001.html, Accessed May 8, 2012.
- European Aviation Safety Agency, http://www.easa.europa.eu, Accessed May 8, 2012.
Copyright © 2012 Hindawi Publishing Corporation. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.