Come Fly With Me: Safety and Human Factors: Bringing Aviation into the Operating Room

Barbara G. Jericho, MD
Department of Anesthesiology University of Illinois Hospital and Health Sciences System Chicago, Illinois

Learning Objectives: As a result of completing this activity, the participant will be able to  Describe the similarities and differences between aviation and health care  Explain the safety methods and tools used in the aviation industry  Describe how health care can utilize the aviation industrys safety methods and tools to improve patient safety  Summarize existing healthcare patient safety initiatives and their roles in patient safety Author Disclosure Information: Dr. Jericho has disclosed that she has no financial interests in or significant relationship with any commercial companies pertaining to this educational activity.

n 1995, Flight 965 crashed into a mountain in Colombia and eight crew members and 152 passengers died.1 This crash was one of many controlled flight into terrain accidents that stimulated the US government to collabo-

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML and PDF text of this article on the Journals Web site (www.asa-refresher.com).

rate with the aviation industry to reduce the risks of aviation accidents. In February 1997, the White House Commission on Aviation Safety and Security challenged the government and the aviation industry to reduce the aviation accident rate by 80% over 10 years.2 Furthermore, the National Civil Aviation Review Commission recommended that the industry and government, represented by the Federal Aviation Administration (FAA), collaborate to develop, implement, and assess the progress of an aviation safety plan.2 As a result, the Commercial Aviation Safety Team (CAST) was formed in 1998.2 The diverse members of CAST include manufacturers, airlines, labor organizations, the Flight Safety Foundation (an international organization), and governmental agencies such as the FAA, National Aeronautics and Space Administration (NASA), the European Aviation Safety Agency/Joint Aviation Authority, and the US Department of Defense.3 Indeed, in a report from June 2010, the fatality risk for commercial aviation in the United States was reduced by 83% in the 10-year period from 1998 to 2008.4 CAST plans to further reduce this fatality risk at least 50% from 2010 to 2025.5 Aviation has achieved a sought-after record of safety. However, the risk of mortality in health care, another highhazard industry, exceeds the fatality risk of aviation, and this figure is not decreasing. The FAA reported that there were 0.4, 6.7, 0.3, and 0.0 commercial aviation fatalities per 100 million persons on board in the years 2008, 2009, 2010, and 2011, respectively.6 In contrast, the Institute of Medicine in 1999 reported that up to 100,000 patients died annually in the United States because of preventable adverse events.7 Ten years later, there does not seem to be an 65

66

Jericho

improvement in these figures. The HealthGrades Patient Safety in American Hospitals Study reported in 2009 that nearly 100,000 Medicare patients alone died because of preventable in-hospital medical errors.8 Medication errors, wrong-site surgery, foreign bodies retained in patients, equipment failure, transfusion errors, and infections continue to be reported9 (Supplemental Digital Content 1, http://links. lww.com/ASA/A136, Supplemental Digital Content 2, http:// links.lww.com/ASA/A137, and Supplemental Digital Content 3, http://links.lww.com/ASA/A138).

affected by human factors. Members of both professions may feel that their decision-making is adequate in both emergent and nonemergent situations; yet, the recognition of the effects of fatigue and a greater display of teamwork were present more in aviation professionals than in those in health care.

Although safety records may differ, aviation and health care share a common factor in the root cause of these adverse events: human factors.
As aviation and health care are both high-hazard industries that share a common factor in the root cause of safety events, one may wonder whether the safety methods and tools of the aviation industry can be applied to health care with similar safety results. This chapter describes safety methods and tools used in the aviation industry that health care can implement in a standardized manner to improve patient safety and employ process improvements within healthcare systems.

The HealthGrades Patient Safety in American Hospitals Study reported in 2009 that nearly 100,000 Medicare patients alone died because of preventable in-hospital medical errors.
Although the safety records may differ, aviation and health care share a common factor in the root cause of these adverse events: human factors. Human factors, in contrast to environmental or equipment causes, constitute the most common cause of aviation accidents.10 Similarly, human factors were the most frequently identified root causes of healthcare sentinel events in 2011 as reported by the Joint Commission11 (Supplemental Digital Content 4, http://links.lww.com/ASA/A139). Specifically in the practice of anesthesia, Cooper et al.12 found that 82% of preventable errors involved human error (Supplemental Digital Content 5, http://links.lww.com/ASA/A140). Sexton and colleagues compared human factors of attitude regarding error, stress, and teamwork of operating room and intensive care unit (ICU) physicians, nurses, fellows, and residents with those of captains and first and second officers from airlines around the world. They found that healthcare workers were more likely than pilots to deny the effects of fatigue on performance; that surgeons were more likely to deny the effects of personal problems on their work compared with pilots, anesthesia staff, and nurses; and that the majority of pilots and medical personnel felt that their decision-making was as good in emergent as in nonemergent situations.13 Also, with regard to teamwork, surgeons perceived teamwork and communication to be of a higher quality compared with the perception of the rest of the medical team.13 Furthermore, in the ICUs, physicians rated teamwork with nurses to be better than nurses rated teamwork with physicians.13 In the same study, trained observers ratings of success of teamwork were greater in aviation than in surgery, anesthesia, and between surgery and anesthesia.13 With regard to the chain of command, Sexton et al.13 found that the majority of pilots, anesthesia staff, and ICU staff, but not surgeons, felt that junior members should question the decisions of senior team members. Thus, the safety of the practice environment in both aviation and health care is

CREW RESOURCE MANAGEMENT

Aviation and CRM
After a fatal crash involving repeated unsuccessful attempts by the second officer to notify the captain that the aircraft had insufficient fuel, the National Transportation Safety Board in 1979 called for a method of crew resource management (CRM) to address training in assertiveness.14 CRM instructs on the use of checklists, effective communication, and assertiveness to clearly articulate discrepancies between what should be and what is actually occurring. Originally known as cockpit resource management, this training was extended to include other aviation team members such as flight dispatchers, cabin crews, and maintenance personnel, and thus became known as CRM. The first comprehensive CRM program in the United States was started in 1981.14 Helmreich and Foushee15 define CRM as optimizing not only the person-machine interface and the acquisition of timely, appropriate information, but also interpersonal activities including leadership, effective team formation and maintenance, problem-solving, decision-making, and maintaining situation awareness. CRM eventually became part of the annual training for crew members and included classroom instruction as well as Line-Oriented Flight training, a simulation-based training program.15 Line-Oriented Flight Training includes team communication before and after the flight simulator and the assessment of crew performance.16 Helmreich et al.17 stated that as there are very few accidents and as there is no specific, standardized CRM training program across all airlines for a uniform comparison,

Come Fly With Me: Safety and Human Factors

67

it would be difficult to validate the effectiveness of CRM in aviation safety. To evaluate CRM in another manner, Salas et al.18 identified and reviewed 58 studies that appraised the effectiveness of aviation CRM training programs. Using four levels of training evaluation identified by Kirkpatrick (reactions, learning, behavior, and results of organizational effectiveness),19 Salas et al.18 described how CRM training fits in that framework (Table 1). Although as Helmreich et al.,17 stated, Sala et al.,18 also found no evidence for the effectiveness of CRM training on aviation safety (organizational effectiveness).

Health Care and CRM

The Institute of Medicine report discussed the contribution of human factors to patient safety.7 In the year 2000, the Institute of Medicine recommended using CRM, because of its success in aviation, to train personnel in critical care divisions.7 Specifically, the Institute of Medicine believes that health care organizations should establish team training programs for personnel in critical care areas (e.g., the emergency department, ICU, and OR) using proven methods such as CRM techniques employed in aviation, including simulation.7 The Joint Commission also recommended team training as a part of its national patient safety plan.20 Since then, CRM training has been adapted to clinical environments with improvements in performance, attitude, and patient safety. Morey et al.21 evaluated the application of training derived from CRM to the emergency department and showed that the clinical error rate decreased significantly from 31% to 4% with improvements Table 1. Appraisal of the Effectiveness of Aviation Crew Resource Management (CRM) Training18
Evidence of CRM Training Effect Aviators like CRM training Perceived to be beneficial to the actions of aviators Leads to positive changes in attitudes Increased cognizance of human factors, crew performance, potential stressors, and the means to address these stressors Allowed individuals to display a greater understanding of CRM principles compared with individuals not instructed in CRM Demonstrated individual behavior (primarily in a simulated environment) that reflected knowledge learned in CRM training Effectiveness of CRM training on aviation safety Level of Training Evaluation* Reaction Reaction Learning Learning

in team behavior, performance, and attitude and opinions toward teamwork. Furthermore, Awad et al.22 showed that CRM training of surgical service staff in the operating room improved communication and patient safety. With the use of preoperative briefings, as shown by Awad et al.,22 the number of patients who received prophylactic antibiotics 1 h before incision and the number of patients who received deep venous thrombosis prophylaxis before induction increased significantly. In summary, aviation CRM training can be adapted to clinical environments with improvements in performance, attitudes, and patient safety. However, unlike CRM in aviation, CRM is not a required part of annual training and is not widely adopted in all healthcare environments and organizations.23

INCIDENT REPORTING
Aviation
The aviation industry has a national reporting system in place to facilitate the reporting of events, identify sources and types of errors, analyze error trends, and provide proactive solutions to avoid fatal accidents. The aviation industrys confidential, nonpunitive, voluntary reporting programs such as the NASA Aviation Safety Reporting System, the collection and analysis of flight recorded data in the Flight Operational Quality Assurance Program, the Voluntary Disclosure Reporting Program, and the Advanced Qualification Program permit the identification of potential safety issues and trends.24,25 Participants in the Aviation Safety Reporting System include not only pilots but also mechanics, air traffic controllers, dispatchers, cabin crew, and ground crew.24 The FAA offers incentives to event reporters, as the FAA will not use the confidentially reported information from Aviation Safety Reporting System in enforcement actions and will waive fines and penalties for unintentional violations of FAA statutes and regulations with certain limitations.24 Reported data (personal names, organizational names, dates, and times) are deidentified and aggregated. The FAA uses the deidentified data to analyze trends with the goal to aim resources to rectify safety issues in the National Airspace System, Air Traffic Control, and flight and airport operations.25 In addition, the Line Operations Safety Audit involves experts on airline flights observing and collecting data from flight crew actions, situational factors, errors and potential errors, and the management of errors by the crew.26 These audits are nonpunitive; that is, flight crews are not held responsible for their observed behaviors or errors, and the data presented from Line Operations Safety Audit are deidentified.26 Moreover, the Aviation Safety Information Analysis and Sharing Program, which is a part of the CAST process, links safety databases across the aviation industry allowing a global review of data from air carriers and the identification of potential adverse events and trends.4 In addition to voluntary, confidential

Learning

Behavior

Organizational effectiveness

*Four levels of training evaluation identified by Kirkpatrick (reactions, learning, behavior, and results of organizational effectiveness).19

68

Jericho

reporting programs, specific events must be reported to the National Transportation Safety Board.27

Health Care
In contrast to the established reporting system in the aviation industry, the reporting system in health care is not well established, nor is it standardized. The communication of deidentified data among national medical organizations and specialties is not practiced consistently. In addition, there are attitude and knowledge barriers to medical reporting. More than 10 years ago, the Institute of Medicine encouraged healthcare organizations to implement voluntary reporting systems so that factors contributing to medical errors could be better understood.7 As a result, medical error reporting systems are present in 27 states and in the District of Columbia.28 Only 12 states require reporting of nosocomial infections.28 However, the reporting of most sentinel events or serious medical errors from individual organizations or specialties to the Joint Commission, a national organization, continues to be voluntary.9 In fact, only 58% of sentinel events reported to the Joint Commission from 2004 to 2010 were self-reported.9 In 2005, the Patient Safety and Quality Improvement Act was passed to encourage the reporting of patient safety events in a voluntary and confidential manner without fear of legal discovery.29 This act creates Patient Safety Organizations (PSOs) and establishes the Network of Patient Safety Databases that analyze collected patient safety data and identify trends of patient safety occurrences.29 The findings are reported each year in AHRQs National Health Quality and Disparities Report. The AHRQ executes the provisions of the Patient Safety and Quality Improvement Act addressing PSOs.30 However, the PSO data do not encompass all errors in health care; for example, laboratory testing errors do not have a standard reporting system database.28 There are 77 PSOs in 31 states and in the District of Columbia that are currently listed by AHRQ.31 PSOs are voluntary and are not federally funded, and any public or private, for-profit or notfor-profit entity can be a PSO. However, health insurance issuers, licensing bodies, and mandatory public reporting systems cannot be PSOs.30 For example, the Anesthesia Quality Institute is a PSO and was created by the American Society of Anesthesiologists in 2008.32 To achieve the safety record of the aviation industry, incident reporting in health care may need to be centralized and standardized. Furthermore, individuals involved in healthcare-related organizations and institutions should be encouraged to report incidents in a confidential and nonpunitive reporting system. Once data are reported, deidentified data can be linked and analyzed to identify trends and near misses. Finally, identified patient safety issues can be communicated to achieve national process improvements in health care. Despite mandates and the presence of healthcare regulatory organizations to address patient safety, barriers to

incident reporting still exist and include the fear of legal liability,31 fear of punitive action or shame and blame,33 lack of a safety culture within an institution, lack of anonymity,33 and lack of feedback to clinicians on what changes will be made on the basis of their reports.34 In a survey by Garbutt and colleagues, over 80% of physicians revealed that they would increase their formal reporting of medical errors in the event of the following: (1) they were assured that the information would be kept confidential; (2) the reported medical errors would not be open to legal discovery and would not result in punitive action; and (3) there was evidence that ensured that changes in the system would be made on the basis of reported medical errors.35 They also showed that surveyed physicians would formally report more medical errors if the process took < 2 minutes (66%) and if the review process of the medical error was confined to their department (53%).35 In addition to attitudes that create barriers to reporting of medical errors, there is also a lack of knowledge on how to report medical errors. Kaldjian et al.36 surveyed physicians in teaching hospitals and found that only 54.8% knew how to report medical errors and only 39.5% knew what errors to report. If the barriers to incident reporting are not overcome and physicians are not educated on error reporting, medical errors and near misses in health care may be more difficult to identify, patient safety trends may not be able to be fully analyzed, process improvements in health care may not advance, and the risk of mortality in health care may continue to escalate. Unlike health care, confidentiality and incentives in the aviation industrys incident reporting system led to more than 975,000 reports of incidents or situations in which aviation safety may have been compromised.24

CHECKLISTS
Aviation
The aviation industry has been using checklists since the 1930s.37 With many tasks to complete before and during a flight, a standardized checklist supports pilots in remembering critical steps and in ensuring that steps are not overlooked for the safe operation of the airplane. Checklists are available for emergency and nonemergency situations including departure, cruising, arrival, forced landings, and flying over mountainous terrain.38 Checklists not only evaluate the aircraft equipment and situation but also the physical and emotional state of the pilot before flight. The IM SAFE checklist assesses the pilot for illness, medication, stress, alcohol, fatigue/food, and emotion.39 The development and approval of all flight crew checklists are overseen by the FAA Principal Operations Inspector.40

Health Care
After observing the successful utilization of checklists as a safety tool in aviation, health care developed checklists

Come Fly With Me: Safety and Human Factors

69

with evidence-based procedures, measured the outcomes, and demonstrated reductions in morbidity and mortality as well as overall improvements in patient safety. Hart and Owen41 investigated the use of an aviation-style checklist for the preparation of a cesarean section under general anesthesia. The researchers found that, with memory alone, important steps in the preparation of the case were forgotten and hence most participants in the study felt that the checklist was useful.41 Furthermore, in a study by Berenholtz et al.,42 a checklist was developed at John Hopkins to help decrease the incidence of infections associated with central line insertion, with a reduction in infection rate from 11% to zero over 1 year. Finally, Haynes et al.43 showed that, after implementing the 19-item World Health Organization surgical safety checklist in the operating room of eight hospitals around the world, postoperative complications and mortality decreased by 36% on average in diverse clinical and economic environments. By successfully utilizing the World Health Organization Surgical Safety Checklist across the world, at least 500,000 deaths could be prevented.44 Therefore, the utilization of checklists in aviation and health care has been shown to be successful in improving both patient and aviation safety. Unlike aviation, however, health care does not have a checklist to address the physical and emotional state of the healthcare worker.

SIMULATION-BASED TRAINING
Simulation-based training allows individuals and teams to practice performing in situations representative of real conditions without actual injury to persons, review decisions and the results of their actions, and receive feedback on responses to the simulated situation-based training. Simulation training is utilized in industries such as aviation as well as in health care and its diverse specialties including surgery, cardiology, radiology, and anesthesiology.4548 In the late 1980s, anesthesiology began using simulators with grant funding support from the Anesthesia Patient Safety Foundation.49 Subsequently, an anesthesia simulation-based curriculum based partly on the principles of CRM called the Anesthesia Crisis Resource Management (ACRM) curriculum was developed and involved simulation scenarios and debriefing.50 ACRM has been adopted at worldwide healthcare institutions and has been utilized by other healthcare specialties. Ideally, to evaluate the effectiveness of ACRM, patient outcomes from simulation-trained physicians would need to be compared with patient outcomes from physicians who did not participate in simulation-based training.48 However, this study would not be feasible to conduct as there are many variables to consider, such as patient comorbidities and complications. Despite the difficulty in assessing the effectiveness of ACRM in this manner, some studies have honed their focus on the participants evaluation of their experiences and the improvement in patient care during specific clinical events after simulation-based training. In a study by Holzman

et al.,48 about 80% of anesthesiologists participating in an ACRM training course revealed that they valued the experience highly and felt the course would improve the safety of their anesthesia practice. In a study by Wayne et al.,51 internal medicine residents who underwent simulation-based training in Advanced Cardiac Life Support exhibited improvement in patient care by exhibiting a greater adherence to the American Heart Association Advanced Cardiac Life Support guidelines compared with residents who did not undergo simulation-based training. Unlike most healthcare staff, airline pilots are required to participate in CRM and simulation-based training.23 Commercial pilots are simulation tested every 6 months for certification in some skills and are tested each year in a high-fidelity team simulator.52 Similarly, the American Board of Anesthesiology has incorporated simulation as one of its Practice Performance Assessment and Improvement (Part IV) requirements for its Maintenance of Certification in Anesthesiology process.53 Interestingly, simulation-based training in health care is not only used for training and fulfilling mandatory requirements but is also considered in the malpractice premium rates of Harvard-affiliated anesthesiologists. The Controlled Risk Insurance Company, the malpractice insurance carrier for Harvard-affiliated physicians, recommended in 2006 a 25% reduction in malpractice premiums for anesthesiologists who have undergone simulation training.54

REGULATION OF WORK HOURS

Sleep deprivation increases the risk of human error-related accidents.55 In fact, Dawson and Reid56equated the decline in psychomotor function from sleep deprivation for 24 hours to an unlawful blood alcohol level of 0.10%. As suggested by a meta-analysis by Philibert,57 physician cognitive performance is negatively affected by sleep deprivation; furthermore, vigilance and clinical performance are more affected by sleep deprivation than are memory and cognitive function. Denisco et al.58 studied the effect of sleep deprivation of anesthesia residents on the performance of simulated critical tasks. The researchers found that those residents who were sleep deprived after a 24hour call shift scored less well on the performance of tasks than did those residents who were well rested.58 Concerns about the negative effects of sleep deprivation and fatigue on resident education, patient safety, and personal wellbeing resulted in the limitation of resident duty hours in 200359; yet, no duty hour limits exist for healthcare staff who are no longer in training. Healthcare staff who have completed their training are still vulnerable to the personal and professional consequences of sleep deprivation and fatigue. Rothschild et al.,60 in a matched retrospective cohort study, found that there was a significant increase in complication rates, attributed to attending surgeons, of post-nighttime surgical cases in which the attending surgeon had 6 hours or less of sleep compared with cases in

70

Jericho

which the attending surgeon had more than 6 hours of sleep. The potential hazardous effects of sleep deprivation are not only recognized in health care but also have affected the safety of passengers in the airline industry. Since 1993, fatigue contributed to seven aviation accidents in the United States, resulting in 250 fatalities.61 To address the concerns of the effect of fatigue on airline accidents, airline pilots work hours are regulated, unlike the work hours of healthcare staff that are no longer in training. Pilots cannot fly for more than 1,000 hours in a calendar year, 100 hours in any calendar month, 30 hours in any 7 consecutive days, and must have 8-hour required rest periods.62

HEALTHCARE PATIENT SAFETY INITIATIVES

In addition to utilizing some of aviations safety tools, health care has implemented a number of initiatives in patient safety at both public and private levels. In 1985, the Anesthesia Patient Safety Foundation was founded by the American Society of Anesthesiologists with a mission of safety education, research and the awarding of research grants, patient safety programs, and the exchange of patient safety information nationally and internationally.63,64 The Anesthesia Patient Safety Foundation is an independent, nonprofit organization comprising a diverse group of board members including anesthesiologists, nurse anesthetists, nurses, manufacturers of equipment and drugs, regulators, risk managers, attorneys, insurers, and engineers.63 Because of their efforts, by the mid 1990s, the insurance risk relativity rating for anesthesiology compared with other medical specialties had been significantly reduced.63 Furthermore, over the last 50 years there has been a significant decrease in anesthesia-related deaths.65 Following the example of the Anesthesia Patient Safety Foundation, in 1997 the American Medical Association and partners established the National Patient Safety Foundation.66 The National Patient Safety Foundation is an independent not-for-profit organization that sponsors patient safety research and education, raises public awareness, and promotes communication about patient safety.67 The Lucian Leape Institute at the National Patient Safety Foundation was established in 2007 to identify new methods to improve patient safety.68 Recent activities at the Lucian Leape Institute include a report focusing on the restructuring of medical student education to address safety in order to strengthen and continue future improvements in overall patient safety.68 In 1997, the Veterans Health Administration established the National Patient Safety Partnership, a public-private partnership, that incorporates visions from the nations experts on patient safety.69 In 1999, the Veterans Health Administration created the National Center for Patient Safety to decrease adverse events and near misses, create a safety culture, and develop patient safety programs and initiatives.70 Following the initiation of the program, the National Center for Patient Safety had a 900-fold increase

in the reporting of near misses of serious events.70 The National Center for Patient Safety has executed and utilizes the Patient Safety Information System, the confidential, nonpunitive electronic reporting system at the Veterans Health Administration.70 Nearly 800,000 safety reports have been recorded in the Patient Safety Information System since 1999.71 Finally, the Leapfrog Group was begun in the year 2000, is driven by employers striving to purchase high-quality health care for their employees, and recognizes hospitals with strong safety records.72 This group focuses on four leaps: Computer Physician Order Entry, Evidence-Based Hospital Referral, ICU Physician Staffing, and Leapfrog Safe Practices Score.73 Lwin and Shepard74state that if all hospitals implemented the first three of Leapfrogs four leaps, or recommended quality and safety practices, over 57,000 lives could be saved, more than three million medication errors could be avoided, and up to $12 billion could be saved each year.

DIFFERENCES AND SIMILARITIES BETWEEN AVIATION AND HEALTH CARE

Aviation and health care are similar in that both are highhazard industries operating with technology. In both professions, safety is of considerable importance. The safety risk, however, in both professions is not consistent; it involves multiple changing variables and can vacillate from a low-risk to a high-risk situation.75 Regulations, legal concerns, and cost issues influence the practice of both of these professions.75 Furthermore, teamwork and effective communication are essential in these complex technological environments.75

Patient safety can be improved through a safe means for people to report events, encouraging reporting to identify areas of potential risk, a well-established and standardized institutional reporting system, a national system to link deidentified data from error reporting databases, identification of trends in reported errors, national communication of findings, and system-based process improvements in health care and patient safety.
When aviation accidents occur, they are usually highly publicized, involve loss of multiple lives at the same time, including the possible deaths of pilots and crew, and involve public reporting of the event after a standardized investigation of the event.75 However, healthcare adverse

Come Fly With Me: Safety and Human Factors

71

events involve loss of individual patient lives, are infrequently publicized, do not involve the death of healthcare staff, and involve a nonstandard investigation and reporting of the event.75 Standardized reporting and investigation of events may be more challenging in health care as it is not centralized like aviation and involves a large number of facilities, diverse specialties, and multiple interrelated constituents (laboratory testing, pharmacies, etc.).

REFERENCES
1. Aviation Safety Network, Database. Available at: http://aviationsafety.net/database/record.php?id 19951220-1. Accessed June 3, 2012. 2. The Commercial Aviation Safety Team. Available at: http:// www.cast-safety.org/about_background.cfm. Accessed June 3, 2012. 3. The Commercial Aviation Safety Team. Available at: http:// www.cast-safety.org/members.cfm. Accessed June 3, 2012. 4. The Commercial Aviation Safety Team, Aviation Group on Track to Meet Safety Goal. Available at: http://www.cast-safety.org/ factsheets.cfm. Accessed June 3, 2012. 5. The Commercial Aviation Safety Team. Available at: http:// www.cast-safety.org/about_vmg.cfm. Accessed June 3, 2012. 6. Federal Aviation Authority. Available at: http://www.faa.gov/about/ plans_reports/performance/quarter_scorecard/. Accessed April 18, 2012. 7. Kohn LT, Corrigan JM, Donaldson MS: To Err Is Human: Building a Safer Health System. Washington: National Academy Press; 1999. 8. HealthGrades Inc. The Sixth Annual HealthGrades Patient Safety in American Hospitals Study 2009. April 2009. Available at: http:// www.healthgrades.com/media/DMS/pdf/PatientSafetyInAmerican HospitalsStudy2009. Accessed June 3, 2012. 9. The Joint Commission June 30, 2011 Summary Data of Sentinel Events Reviewed. Available at: http://www.jointcommission.org/ assets/1/18/SE_Stats_Summary_2Q_20111.PDF. Accessed November 19, 2011. 10. National Transportation Safety Board. Annual review of aircraft accident data U.S. General Aviation, Calendar Year 2006. July 2010. 11. The Joint Commission: Sentinel Event Data - Root Causes by Event Type 2004-2011. Available at: http://www.jointcommission.org/ assets/1/18/Root_Causes_Event_Type_2004-2011.pdf. Accessed April 17, 2012. 12. Cooper JB, Newbower RS, Long CD, et al.: Preventable anesthesia mishaps: a study of human factors. Anesthesiology 1978; 49:399406. 13. Sexton JB, Thomas Eric J, Helmreich RL: Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ 2000; 320: 745749. 14. Helmreich RL, Merritt AC, Wilhelm JA: The evolution of crew resource management training in commercial aviation. Int J Aviation Psychol 1998; 9:1932. 15. Helmreich RL, Foushee HC: Why CRM? Empirical and theoretical bases of human factors training. In: Kanki B, Helmreich RL, Anca J, eds. Crew Resource Management. San Diego: Elsevier; 2010:5. 16. Federal Aviation Authority. Available at: http://rgl.faa.gov/Regula tory_and_Guidance_Library/rgAdvisoryCircular.nsf/list/AC%2012035C/$FILE/AC120-35c.pdf. Accessed June 3, 2012. 17. Helmreich RL, Chidester TR, Foushee HC, et al.: How effective is cockpit resource management training? Exploring issues in evaluating the impact of programs to enhance crew coordination. Flight Saf Dig 1990; 9:117. 18. Salas E, Burke CS, Bowers CA, et al.: Team training in the skies: does crew resource management (CRM) training work. Human Factors 2001; 43:641674. 19. Kirkpatrick DL: Evaluation of training. In: Craig RL, ed. Training and Development Handbook: A Guide to Human Resources Development. New York: McGraw-Hill; 1976:18.118.27. 20. Joint Commission 2005 Health Care at the Crossroads: Strategies for Improving the Medical Liability System and Preventing Patient Injury. Available at: http://www.jointcommission.org/assets/1/18/ Medical_Liability.pdf. Accessed November 19, 2011. 21. Morey JC, Simon R, Jay GD, et al.: Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health Serv Res 2002; 37:15531581. 22. Awad SS, Fagan SP, Bellows C, et al.: Bridging the communication gap in the operating room with medical team training. Am J Surg 2005; 190:770774. 23. 14CFR121.419. Available at: http://edocket.access.gpo.gov/cfr_2002/ janqtr/14cfr121.419.htm. Accessed November 19, 2011. 24. Aviation Safety Reporting System, Confidentiality and Incentives to Report. Available at: http://asrs.arc.nasa.gov/overview/confidentiality. html. Accessed June 3, 2012. 25. Federal Aviation Authority. Available at: www.faa.gov/about/initiatives/ atos/air_carrier/foqa/. Accessed June 3, 2012. 26. Line Operations Safety Audit. International Civil Aviation Organization 2002. Available at: http://legacy.icao.int/anb/humanfactors/LUX2005/ Info-Note-5-Doc9803alltext.en.pdf. Accessed June 3, 2012.

CONCLUSIONS
Despite the differences between aviation and health care, the use of successful aviation safety practices in health care has resulted in improvements in patient safety. Improving the safety of health care is paramount. Restructuring healthcare systems by incorporating the lessons and tools we have acquired from aviation, an industry that has improved safety by leaps and bounds, can only continue to improve patient safety. As described, there are differences between aviation and health care, but the underlying principles can be shared because of their overwhelming similarities. To advance the safety record of health care, it is essential to educate healthcare workers and ancillary staff as well as medical students and residents in such topics as patient safety, the reporting of adverse events and near misses, and human factors and their effects on patient safety. In addition to education, patient safety in health care can be improved as follows: (1) the creation of a safety culture consistently present to ensure that individuals report events and near misses in a confidential and nonpunitive system, an approach that could remove barriers to reporting; (2) the encouragement of reporting of safety events to identify areas of potential risk and prevent adverse events; (3) the development of a well-established and standardized reporting system to include all types of healthcare delivery systems and healthcare professionals as health care, unlike aviation, is decentralized; (4) the development of a system to link deidentified data from errorreporting databases nationally; (5) the identification of trends in reported errors; (6) the national communication of findings to healthcare delivery systems and individuals; and (7) the institution of system-based process improvements in health care and patient safety. With these goals in mind, let us challenge health care to meet the CAST goal in aviation: to reduce the mortality risk in health care at least 50% from 2010 to 2025.5

ACKNOWLEDGMENTS
Come Fly With Me was composed by Jimmy Van Heusen with lyrics by Sammy Cahn. The author thanks Hal Leonard Corporation, Maraville Music Corporation, Warner Chappell, Alfred Music Publishing, and Barton Music and Affiliates for permitting the use of the song title.

72

Jericho

27. Federal Aviation Authority. Available at: http://www.faa.gov/library/ manuals/aviation/media/faa-h-8083-19A.pdf. Accessed June 3, 2012. 28. Golemboski K: Improving patient safety: lessons from other disciplines. Clin Lab Sci 2011; 24:114119. 29. Agency for Healthcare Research and Quality. Available at: http:// www.ahrq.gov/qual/psoact.htm. Accessed June 3, 2012. 30. Agency for Healthcare Research and Quality. Available at: http:// www.pso.ahrq.gov/psos/fastfacts.htm. Accessed June 3, 2012. 31. Agency for Healthcare Research and Quality. Available at: http:// www.pso.ahrq.gov/listing/geolist.htm. Accessed June 3, 2012. 32. Anesthesia Quality Institute. Available at: http://aqihq.org/faqs.aspx. Accessed June 3, 2012. 33. Kaldjian LC, Jones EW, Rosenthal GE, et al.: An empirically derived taxonomy of factors affecting physicians willingness to disclose medical errors. J Gen Intern Med 2006; 21:942948. 34. Evans SM, Berry JG, Smith BJ, et al.: Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care 2006; 15:3943. 35. Garbutt J, Waterman AD, Kapp JM, et al.: Lost opportunities: how physicians communicate about medical errors. Health Affairs 2008; 27:246255. 36. Kaldjian LC, Jones EW, Wu BJ, et al.: Reporting medical errors to improve patient safety: a survey of physicians in teaching hospitals. Arch Intern Med 2008; 168:4046. 37. Schamel J. How the pilots checklist came about. 2011. Available at: http://www.atchistory.org/History/checklst.htm. Accessed June 4, 2012. 38. CheckMate Aviation. Available at: http://www.checkmateaviation. comww.checkmateaviation.com. Accessed June 3, 2011. 39. Federal Aviation Authority. Available at: http://www.faa.gov/air_traffic/ publications/ATpubs/AIM/aim0801.html. Accessed June 3, 2012. 40. Federal Aviation Authority at http://fsims.faa.gov/PICDetail.aspx? docId 74518EFFD4ACD8068525734F007665E3. Accessed June 3, 2012. 41. Hart EM, Owen H: Errors and omissions in anesthesia: a pilot study using a pilots checklist. Anesth Analg 2005; 101:246250. 42. Berenholtz SM, Pronovost PJ, Lipsett PA, et al.: Eliminating catheterrelated bloodstream infections in the intensive care unit. Crit Care Med 2004; 32:20142020. 43. Haynes AB, Weiser TG, Berry WR, et al.: A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360:491499. 44. World Health Organization. Available at: http://www.who.int/ patientsafety/safesurgery/en/index.html. Accessed June 3, 2011. 45. Aggarwal R, Undre S, Moorthy K, et al.: The simulated operating theatre: comprehensive training for surgical teams. Qual Saf Health Care 2004; 13(Suppl 1):i27i32. 46. Sica GT, Barron DM, Blum R, et al.: Computerized realistic simulation: a teaching module for crisis management in radiology. AFR 1999; 172:301304. 47. Ewy GA, Felner JM, Juul D, Mayer JW, et al.: Test of a cardiology patient simulator with students in fourth year electives. J Med Educ 1987; 62:738743. 48. Holzman RS, Cooper JB, Gaba DM, et al.: Anesthesia crisis resource management: Real-life simulation training in operating room crisis. J Clin Anesth 1995; 7:675687. 49. Anesthesia Patient Safety Foundation. Available at: http://www.apsf. org/about_history.php. Accessed June 3, 2012. 50. Howard SK, Gaba DM, Fish KJ, et al.: Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 1992; 63:763770. 51. Wayne DB, Didwania A, Feinglass J, et al.: Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: A case-control study. Chest 2008; 133:5661.

52. Ziv A, Small SD, Wolpe PR: Patient safety and simulation-based medical education. Medical Teach 2000; 22:489495. 53. The American Board of Anesthesiology. Available at: www. theaba.org/Home/anesthesiology_maintenance. Accessed November19, 2011. 54. Hanscom R: Medical simulation from an insurers perspective. Acad Emerg Med 2008; 15:984987. 55. Dinges DF: An overview of sleepiness and accidents. J Sleep Res 1995; 4:414. 56. Dawson D, Reid K: Fatigue, alcohol and performance impairment. Nature 1997; 388:235. 57. Philibert I: Sleep loss and performance in residents and nonphysicians: A meta-analytic examination. Sleep 2005; 28:13921402. 58. Denisco RA, Drummond JN, Gravenstein JS: The effect of fatigue on the performance of a simulated anesthetic monitoring task. J Clin Monit 1987; 3:2224. 59. Accreditation Council for Graduate Medical Education, Common program requirements for duty hours. Approved June 24, 2003. Available at: http://www.acgme.org/acWebsite/ci/ci_resident_duty_ hours.asp. Accessed June 5, 2012. 60. Rothschild JM, Keohane CA, Rogers S, et al.: Risks of complications by attending physicians after performing nighttime procedures. JAMA 2009; 302:15651572. 61. Sumwalt R: Reduce aviation accidents and incidents caused by fatigue: Its time to act!" Aviation Fatigue Management Symposium: Partnerships for Solutions. June 17, 2008. Available at: http:// www.faa.gov/about/office_org/headquarters_offices/avs/offices/afs/ afs200/media/aviation_fatigue_symposium/aviation_fatigue_sym posium.pdf. Accessed June 3, 2012. 62. Federal Aviation Regulations (FARS, 14 CFR, Part 121.471). Available at: http://www.flightsimaviation.com/data/FARS/part_ 121-471.html. Accessed June 3, 2012. 63. Anesthesia Patient Safety Foundation. Available at: http://www.apsf. org/about_history.php. Accessed June 3, 2012. 64. Anesthesia Patient Safety Foundation. Available at: http://www.apsf. org/about.php. Accessed June 3, 2012. 65. American Society of Anesthesiologists. Available at: http://www. asahq.org/for-the-public-and-media/press-room/anesthesia-fast-facts. aspx. Accessed June 3, 2012. 66. National Patient Safety Foundation. Available at: http://www. npsf.org/about-us/history-and-timeline/. Accessed June 3, 2012. 67. National Patient Safety Foundation. Available at: http://www.npsf. org/about-us/mission-and-vision/. Accessed June 3, 2012. 68. National Patient Safety Foundation. Available at: http://www.npsf. org/about-us/lucian-leape-institute-at-npsf/. Accessed June 3, 2012. 69. United States Department of Veterans Affairs. Available at: http:// www1.va.gov/opa/pressrel/pressrelease.cfm?id 176. Accessed June 3, 2012. 70. Heget JR, Bagian JP, Lee CZ, et al.: System innovation: veterans health administration national center for patient safety. Joint Commission Journal on Quality and Patient Safety 2002; 28:660665. 71. United States Department of Veterans Affairs. Available at: http:// www.va.gov/health/NewsFeatures/20110610a.asp. Accessed June 3, 2012. 72. The Leapfrog Group for Patient Safety. Available at: http:// www.leapfroggroup.org/about_leapfrog. Accessed June 3, 2012. 73. The Leapfrog Group for Patient Safety. Available at: http://www. leapfroggroup.org/about_leapfrog/leapfrog-factsheet. Accessed June 3, 2012. 74. Lwin AK, Shepard DS: Estimating lives and dollars saved from universal adoption of the leapfrog safety and quality standards: 2008 update. Schneider Institutes for Health Policy. Washington, DC: Prepared for The Leapfrog Group; 2008. 75. Helmreich RL: On error management: lessons from aviation. BMJ 2000; 320:781785.