National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac surgery: error cycles precede ∼85% of patient deaths

The Journal of Thoracic and Cardiovascular Surgery
Edward J HickeyGlen S Van Arsdell

Abstract

We hypothesized that the National Aeronautics and Space Administration "threat and error" model (which is derived from analyzing >30,000 commercial flights, and explains >90% of crashes) is directly applicable to pediatric cardiac surgery. We implemented a unit-wide performance initiative, whereby every surgical admission constitutes a "flight" and is tracked in real time, with the aim of identifying errors. The first 500 consecutive patients (524 flights) were analyzed, with an emphasis on the relationship between error cycles and permanent harmful outcomes. Among 524 patient flights (risk adjustment for congenital heart surgery category: 1-6; median: 2) 68 (13%) involved residual hemodynamic lesions, 13 (2.5%) permanent end-organ injuries, and 7 deaths (1.3%). Preoperatively, 763 threats were identified in 379 (72%) flights. Only 51% of patient flights (267) were error free. In the remaining 257 flights, 430 errors occurred, most commonly related to proficiency (280; 65%) or judgment (69, 16%). In most flights with errors (173 of 257; 67%), an unintended clinical state resulted, ie, the error was consequential. In 60% of consequential errors (n = 110; 21% of total), subsequent cycles of additional error/unintended states occu...Continue Reading

References

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Citations

Dec 14, 2016·The Annals of Thoracic Surgery·Edward HickeyGlen Van Arsdell
Nov 3, 2017·Conservation Biology : the Journal of the Society for Conservation Biology·Allison S CatalanoAndrew T Knight
Mar 23, 2017·European Journal of Emergency Medicine : Official Journal of the European Society for Emergency Medicine·Marck H T M HaerkensPeter Pickkers
Mar 8, 2019·World Journal for Pediatric & Congenital Heart Surgery·Brett R AndersonUNKNOWN Congenital Heart Technical Skill Study
May 22, 2019·The British Journal of Surgery·A S H M van DalenM P Schijven

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