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Journal of Healthcare Engineering
Volume 3 (2012), Issue 3, Pages 373-390
http://dx.doi.org/10.1260/2040-2295.3.3.373
Research Article

Learning from Aviation to Improve Safety in the Operating Room - a Systematic Literature Review

Linda S. G. L. Wauben,1,2,3 Johan F. Lange,2 and Richard H. M. Goossens3,4

1Department of BioMechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Delft, The Netherlands
2Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands
3Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
4Department of Neuroscience, Erasmus University Medical Center, Rotterdam, The Netherlands

Received 1 December 2011; Accepted 1 March 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.

Linked References

  1. 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. View at Google Scholar
  2. 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. View at Google Scholar
  3. 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. View at Google Scholar
  4. 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. View at Google Scholar
  5. 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. View at Google Scholar
  6. 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. View at Google Scholar
  7. 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.
  8. 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. View at Google Scholar
  9. J. Reason, “Human error: models and management,” BMJ, vol. 320, no. 7237, pp. 768–770, 2000. View at Google Scholar
  10. 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. View at Google Scholar
  11. J. Dankelman and C. A. Grimbergen, “Systems approach to reduce errors in surgery,” Surg Endosc, vol. 19, no. 8, pp. 1017–1021, 2005. View at Google Scholar
  12. A. Cuschieri, “Nature of Human Error. Implications for Surgical Practice,” Ann. Surg, vol. 244, no. 5, pp. 642–648, 2006. View at Google Scholar
  13. 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. View at Google Scholar
  14. 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. View at Google Scholar
  15. 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. View at Google Scholar
  16. 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. View at Google Scholar
  17. R. L. Helmreich, “On error management: lessons from aviation,” BMJ, vol. 320, no. 7237, pp. 781–785, 2000. View at Google Scholar
  18. 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. View at Google Scholar
  19. S. Arora and N. Sevdalis, “Systems Approach to daily clinical care,” Int J Surg, vol. 8, no. 2, pp. 164–166, 2010. View at Google Scholar
  20. 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. View at Google Scholar
  21. 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. View at Google Scholar
  22. 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. View at Google Scholar
  23. 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. View at Google Scholar
  24. 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. View at Google Scholar
  25. 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. View at Google Scholar
  26. 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.
  27. 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.
  28. 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. View at Google Scholar
  29. 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. View at Google Scholar
  30. 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. View at Google Scholar
  31. 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. View at Google Scholar
  32. T. W. Nolan, “System changes to improve patient safety,” BMJ, vol. 320, no. 7237, pp. 771–773, 2000. View at Google Scholar
  33. 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. View at Google Scholar
  34. 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. View at Google Scholar
  35. 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. View at Google Scholar
  36. 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. View at Google Scholar
  37. M. Muller, “Safety lessons taken from the airlines,” Br J Surg, vol. 91, no. 4, pp. 393–394, 2004. View at Google Scholar
  38. 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. View at Google Scholar
  39. 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. View at Google Scholar
  40. 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. View at Google Scholar
  41. 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. View at Google Scholar
  42. World Health Organization, WHO Guidelines for Safe Surgery, first edition, 2008.
  43. 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. View at Google Scholar
  44. 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. View at Google Scholar
  45. 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. View at Google Scholar
  46. 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. View at Google Scholar
  47. 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. View at Google Scholar
  48. 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. View at Google Scholar
  49. Federal Aviation Administration, http://rgl.faa.gov, Accessed May 8, 2012.
  50. UK Civil Aviation Authority, http://www.caa.co.uk, Accessed May 8, 2012.
  51. 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.
  52. European Aviation Safety Agency, http://www.easa.europa.eu, Accessed May 8, 2012.