Maneechaeye et al.
Operating Room and Flight Deck: What Do These Places Have in Common?
Pattarachat Maneechaeye, B.Acc, MBA, Ph.D.*, Watcharaphat Maneechaeye, M.D., M.Sc.**, Wisanupong Potipiroon, B.A., M.S., Ph.D.***
*Ph.D. Candidate, Faculty of Management Sciences, Prince of Songkhla University, Songkla 90112, Thailand, **Occupational Medical Doctor and Fort Hospital Vice Director, Fort Khunchueangthammikkarat Hospital, Payao 56000, Thailand, ***Faculty of Management Sciences, Prince of Songkhla University, Songkla 90112, Thailand.
ABSTRACT
This review article grounds itself into the advent of aviation safety concepts that share some aspects into healthcare industry, practically and theoretically. These concepts are originally invented for
a review of literatures. This review article contributes to |
a broader knowledge from |
both |
fields of |
work regarding |
operational safety. The review shows that there are several |
practical concepts including |
Crew |
Resource |
Management, |
checklists and readbacks, sterile cockpit, and human factors of fatigue and stress that healthcare professionals can adopt and adapt them into their daily operation. Moreover, theoretical concepts such as Swiss cheese model and Threat and Error Management can be applied into healthcare context. This review invokes scenarios of each concept from both industries. The results show that communication is the key to promote safer operation and those concepts can be adopted to promote better safety at work. Future studies should extend the concepts of this review into an experimental research to analyze the effect of concepts on actual healthcare settings or utilize qualitative study to investigate the application of concepts in healthcare environment.
Keywords: Aviation; patient safety; pilot; safety; surgeon; surgery (Siriraj Med J 2021; 73:
INTRODUCTION
Safety is essential and considered an utmost goal in aviation. The problem is that aviation accidents always result in enormous loss of life and assets, attracting worldwide attention as well as huge financial costs for all stakeholders. Therefore, the aviation industry is rigorously determined to learn from past lessons from incidents and accidents to prompt better safety procedures and practices. In terms of the rules in pilots’
standard operating procedures, there is always someone who has paid for it with their life. In an honest, sincere and truthful way, pilots’ standard operating procedures are written in blood. Thereby, pilots have an interest in conforming to the rigorous safety policies and procedures they must follow as the probability exists that they would pay for any shortcomings of the safety procedures with their own lives as well. These are the reasons why the aviation industry has instigated a dominant
Corresponding author: Pattarachat Maneechaeye
Received 22 June 2021 Revised 315 August 2021 Accepted 31 August 2021 ORCID ID:
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safety culture. However, pilot error seems to remain the primary cause of aviation accidents.1 On the other hand, medical errors in the healthcare industry provide a serious threat to patient safety as they are estimated to be accountable for 3% of all hospital admissions.2 Toward the goal of reducing the risk of patient harm, the notion of aviation safety policies and practices may be adopted for the medical field, especially for surgeons. Both the operating room in a hospital and the cockpit in an aircraft, surgeons and flight crews, share a lot of things in common in terms of rigorous training,
The objective of this review article is to scrutinize the advent concepts of aviation safety that may be applicable to the healthcare industry. Data collection was based upon a systematic review of related literature including texts, research papers, practitioner papers, academic manuscripts, and other relevant online resources from both academic and practitioner perspectives. This review article contributes to a broader knowledge from both fields of work regarding operational safety.
Described below are reviews of several aviation safety concepts, practically and theoretically, that have been introduced and could possibly be adapted into medical practices. This review article also aims to incorporate existing
Practical Concepts
Crew Resource Management (CRM)
Hazard industries, namely healthcare and aviation, rely mostly on effective teamwork exercise owing to the complicate, dynamic and critical safety nature context of their industries. It is inadequate that these teams are built upon individual experts, but the team itself must be high expertise team in order to practice high level of technical performance and team attitudes and behaviors to function safely and adaptively to achieve goals. An expert team is defined as a set of interdependent team members, each of whom possesses unique and
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in that they operate in
Apart from those CRM factors aforementioned, there are several crucial elements regarding CRM practices that describe safer operation among aviation and medical practitioners alike. These are situation awareness, decision making and SHELL Model.
Situation awareness comprises three stages which are, the perception of the elements in the environment in a matter of current time and space orientation, the comprehension of their meaning and the projection of their status in the near future and thus, proper decision making is made to mitigate risks.7 With these three components combined, situation awareness may support better choice of action as this involves cognition and
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that the heart is filling up with blood or full heart. The good
According to SHELL model in Fig 1, this model can help understand human factor element in CRM concept. The SHELL model is a conceptual model of human factors that helps clarify the human factor relationships between resource, system, environment and human.12 The model represents several wavy squares to illustrate different elements of imperfect interacting components which are Software (policies, procedures, practices), Hardware (machines, aircraft), Environment (working context) and Liveware (man). The core component of this model is the man (Liveware), flight crew or operating room crew in this case, and this is considered as the most sensitive system component as human is subject to great variation in performance and limitation and all other components ought to be adapted to fit with this centered Liveware such as
801.First officer and flight engineer failed to challenge captain for the wrong ground base radio navigation aid
approach and captain did not listen to his subordinates then the aircraft crashed into the hill about 3 nautical miles short of the runway.15 To mitigate
Fig 1. SHELL Model Adapted from ICAO
Both healthcare and aviation are high reliable industries and specific training is necessary. Crew Resource Management (CRM) concept is introduced to support and enhance teamwork exercise and team performance. CRM is the effective use of all available resources for flight crew personnel to assure a safe and efficient operation, reducing error, avoiding stress and increasing efficiency17. This type of training incorporates
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between surgeons and anesthesiologist needs to be resolved by absolute consensus as these two professions share the same level of responsibility. While in aviation, captain or
Checklists and readbacks
In aviation context, checklists have been developed for each phase of the flight mission including taxi, takeoff, climb, level flight, descend, approach and landing as well as for emergency situations that may arise during mission. Pilots are strongly encouraged and committed to abide by these checklists and any deviation from checklists is considered a flight regulation violation. Moreover, checklists are specifically designed to the specific type of aircraft to assure that all
Effective, yet efficient communication is determined as a very basic human necessity which is particularly essential to assure safety in
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repeating it back verbally to the sender and this will let the sender know the message has been received and provides a chance to correct any discrepancies. Some past air accidents involving poor communication between pilots and air traffic controller and this emphasizes that human errors in communication still occur even in advances technology in aviation. On the contrary, it is essential to develop communication phraseology or standard protocols in
Sterile cockpit
Even though an operating room is literally sterile for sanitary purpose, sterile cockpit, in aviation context, does not mean that the flight deck is sanitized by any disinfection agents. It means that the flight crews in the cockpit keep the environment of a cockpit safe from all
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Human factors: fatigue and stress
Fatigue is one of the most common physiological problems for flight crews and will adversely affect individuals who are otherwise in good health condition. It has frequently been considered as the causal factor in aviation incidents and accidents as fatigue degrades performance and tired flight crews cannot carry out flying tasks as reliably and accurately as they should normally perform. Moreover, They are irritable and less alert, willing to accept lower standards of accuracy and performance.39 Fatigue begins when the pilot commences a flight continuously and increases with each hour in the air. As a result, at the time of landing when reflexes
and judgement should be at high, the pilot is most affected by the cumulative effects of fatigue. In addition, the major danger of fatigue is that it is cumulative and the pilot might not recognize its effect. Fatigue can be caused by many factors such as lack of sleep, poor food,
Stress indeed is generated by the task itself and it is not always negative as the sympathetic nervous system responds to stress and supplies the resources to deal with the upcoming demands. Factors contributing to stress are generally classified into three categories which are physical, physiological and psychological stressors. Physical stressors include extreme temperature, noise, vibration, lack of oxygen, etc. Physiological stressors include fatigue, hunger, disease, etc. Psychological stressors relate to emotional factors such as worries, poor personal relationship, financial problem, etc.45 It is quintessential that both pilot and surgeon are able to recognize when stress levels are getting too high. If they are suffering from domestic stress, divorce, bereavement or even moody sensation, the cockpit or operating room might not be suitable places for them. Besides, the stress of flying or operating also consume energy. This energy is derived from oxygen and blood sugar. Pilots who fly for too long without eating or surgeons who operate procedures for too long and skip meal will face low blood sugar or hypo glycaemia; that is to say, their energy reserve will be low and cause reactions to be sluggish and effect their work performance drastically.46 Due to
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and medical fitness. This ensures adequate operational safety in every flight. Sign of chronic stress are varied such as forgetfulness, repeated mistakes, tense stomach and it may erode individuals’
Theoretical concepts
Swiss cheese model
Swiss cheese model, portrayed in Fig 2, was hypothesized that most accidents or incidents could be traced to one or more of four level of failure that had been placed in order consecutively.51 These four levels of failure include organizational influences (organization- level), unsafe supervision (supervision controls), preconditions for unsafe acts
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human error is a general symptom of system failures that demands explanation.52
In aviation context, for instance, even when many things can go wrong such as an aircraft traffic separation infringement in case that the traffic conflict is not regarded or resolved by air traffic controller, pilots or traffic collision avoidance system (TCAS) in the aircraft will still get the job done and cause a very small chance that aircraft may collide each other midair. Air traffic controller inability to resolve conflict traffic is considers and a threat that pass through a hole of one cheese but pilot and TCAS ability to detect conflict traffic is another cheese that block this threat to pass through. However, if threat can pass through all the layers of cheese, accident or incident can be anticipated. In aviation scenarios, flight crew working for an airline that has poor safety procedure (organization influence) with poor pilot training record and supervision (unsafe supervision) are operating a commercial flight, when there is an air traffic conflict during critical final approach (precondition of unsafe acts), pilots ignore cautions from both TCAS and air traffic controller (unsafe acts). In this case all holes in the cheese will line up straights and threats will get through all cheese layers and cause a serious accident. In operating room context, a vascular surgeon working for a hospital that has marginal standard operating procedure (organization influence) with
Fig 2. Swiss Cheese Model Adapted from James Reason
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forceful femoral pulses and the perceived hypotension. It is also recognized that
Threat and error management
Originally, threat and error management model may be developed for flight deck operation; nevertheless, this can be used at healthcare or other industries as well. Threat and Error Management (TEM) is a conceptualized framework that helps in understanding, from an operational perspective, the
Threats are defined as events or errors that occur beyond the influence of the flight crew, increase operational complexity and which must be managed to maintain the margins of safety.56 During operation, flight crews need to manage various external complexities. such as adverse meteorological condition, air traffic congestion and aircraft technical malfunction. Some threats can be anticipated as they are expected to flight crews such as adverse meteorological condition and air traffic. These can be found in notice to airman (NOTAM) and weather forecast information. However, some threats cannot be anticipated such as
early and instantly pass aircraft flight control to
Error are defined as actions or inactions by the flight crews that lead to deviations from flight crews intentions or expectations.58 Unmanaged or mismanaged errors mostly lead to undesired aircraft stated and error in the operational context hence leads to reduce the margins of safety and increase the possibility of adverse events to occur. Despite the modern aircraft computer technology, erroneous pilot can input incorrect flight parameter into flight computer and this will lead to future adverse event. Regardless of the error types, errors effect on safety depends upon whether the flight crews detect and responds to the error before it may lead to an adverse event or potential unsafe outcome. From the safety aspects, operational errors that are timely detected and promptly responded to will not reduce margins of safety; besides, proper error management represents an example of successful human performance.59,60 To simplify, errors are something bad that arise from the pilots.
Undesired Aircraft States (UAS) are defined as flight
In healthcare context, disturbing sound made by an overly excited orthopedic surgeon in the operating room nearby or inexperience crewmates performing incorrect procedure may contribute to reduced levels of concentration of a surgeon and these can be considered as threats. Moreover, overwork that causing fatigue and stress and surgeon’s poor health condition can be considered as internal threats that affect human factor and limitations. Mismanaged operating treatment or failure to following standard operating procedure due to various factors that are stemmed from surgeon can be regarded as error. A sign of sudden drop in blood pressure and patient arrest are, in this case, considered as undesired aircraft states.
According to Fig 3, at the top of the inverted triangle is considered as safe operations. That is where the operation always strives to be; nonetheless, pilots and
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surgeons experience several threats during their mission. Therefore, they should constantly be prepared for those threats to maintain a safe operation. In addition, apart from threat, several errors stemmed from pilots and surgeons can be anticipated. They need to instantly act accordingly to prevent further adverse event that will lead to undesired aircraft states and eventually accident.62 Proper communication also plays an important role in TEM. It was regarded as Concerned, Uncomfortable and Safety (CUS) words. If surgeons hear another teammate says “I am concerned.”, “I feel uncomfortable about this.”, or “Patient safety is currently being compromised.”, they should stop what they are doing and listen to address those concerns accordingly.
Fig 3. Threat and Error Management Model Adapted from United Airlines
All in all, both practical and theoretical concepts regarding safety can be summarized as shown in Table 1.
DISCUSSION
According to the four operational concepts and two theoretical concepts of aviation safety mentioned previously, it can be seen that there is one element that the concepts have in common, which is “communication”. This finding shares the same insight corresponding with past research concerning the impact of communication in
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their ego at work and listen to their team members even more. Even seasoned or
As mentioned earlier, both aviation and health care are
CONCLUSION
This review article aims to portray
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TABLE 1. Summary of Practical Concepts and Theoretical Concepts in Safety.
Safety Concepts Aviation Context |
Healthcare Context |
Similarities |
Differences |
|
|
|
|
Crew Resource |
- Two pilots, which are Captain and |
Management |
First Officer, work with Cabin Crew, |
(CRM) |
Engineer and Air Traffic Controller |
|
within the flight mission. |
- Surgeon works with |
- Team working operates in |
- |
Anesthesiologist, Anesthetist, |
environments. |
responsible for absolute decision. |
Medical Technician within the |
- Team members are skillful and professional |
- Disagreement needs to be solved by |
operating room. |
and always change in difference tasks. |
consensus from both surgeon and |
|
|
anesthesiologist. |
Checklists |
- Checklists are mandatory and any |
- Checklists are optional. |
- Checklists have been designed to suite |
- In aviation, checklists are mandatory. |
|
deviation from checklists is |
- Surgical Checklists proposed by |
different phrase or different progress of |
- In healthcare checklists are optional. |
|
considered as a violation. |
WHO can be edited to suite different |
work. |
|
|
- Checklists have been developed for |
interests of interventions. |
|
|
|
each phase of the flight. |
|
|
|
Readbacks |
- A procedure whereby the receiving |
|
station repeats a received transmitted |
|
message or an appropriate part |
|
thereof back to the transmitting |
|
station to attain confirmation of |
|
correct reception. |
-The person receiving information repeats it back verbally to the sender and the sender will know whether the message has been received correctly.
-The concept of
-In flight, readbacks are required as a transmission over radio frequency might not be clear due to radio noise and frequency interruption.
-In healthcare, readbacks are encouraged in the critical phase of clinical communication to promote more patient safety.
Sterile Cockpit |
- Flight crews keep the environment |
|
of a cockpit free from all |
|
conversation during critical phases |
|
of flight. |
Human Factor: |
- Fatigue begins after a long flight |
Fatigue |
hour. |
Human Factor: |
- Stress is generated by continuous |
Stress |
challenges at flight mission. |
- Operating crews encourage each |
- The notion of “staying focus” on the critical |
- Flight deck is isolated and |
other to regain a focus in a critical |
phase of work. |
- Operating room is |
phase of procedure. |
|
a cockpit with more distractions from both |
|
|
inside and outside |
- Fatigue begins after a long hour |
- Fatigue degrades work performance. |
- Flight duty time is regulated by law. |
of clinical work. |
|
- Management and surgeons need to set a |
|
|
middle ground on working hour. |
- Stress is generated by the |
- Mind stress is acceptable but intensive |
- Annually, every pilot needs to pass both |
operating task itself. |
stress will deteriorate work performance. |
physical and mental fitness examination |
|
|
before flight. |
|
|
- Physical and mental fitness examination is |
|
|
not required to perform duty in healthcare. |
Swiss Cheese |
- Four levels of failure can be poor |
Model |
SOPs, inadequate training, instrument |
|
failure and poor piloting technique |
-Four levels of failure can be poor
SOPs, insufficient training, poor operating tools technique, and improper operating skill
-Four levels of failure include organizational influence, unsafe supervision, preconditions for unsafe acts and unsafe acts.
-Aviation accident result in enormous loss of lives and assets and pilots pay it with their own life.
-Failure in operating room cause a single loss of life.
Threat and Error |
- Threat: Bad weather, congested air |
- Threat: Improper procedure |
- Threat is considered as an external factor. |
- In aviation, in spite of advance technology of |
Management |
traffic, technical failure. |
performed by inexperience teammate. |
- Error is regarded as an internal factor. |
aircraft computer, aircraft automation can be |
(TEM) |
- Error: Poor piloting technique, |
- Error: Mismanaged operating |
- Undesired Aircraft States (UAS) is a result |
overridden by erroneous pilot. |
|
cockpit mismanagement. |
treatment by surgeon. |
from threat and error and this considered |
- In operating theater, error can be prevented |
|
- UAS: Improper airspeed, Failure to |
- UAS: A sign of sudden drop in |
as a last chance to correct to prevent future |
by suitable communication between crews. |
|
maintain glide path during approach. |
blood pressure, patient arrest. |
adverse event. |
|
|
|
|
|
|
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obvious similarities between these two professions, there are a number of differences as well. Besides, the implementation of aviation safety practices and concepts in the surgical context may be less than optimal. For example, pilots are required to conform to flight duty time strictly as this is regulated by law. Nonconformity to this rule and overworking as a pilot can be considered a serious safety violation; both the pilots and their airlines will be penalized accordingly. However, long working hours contributing to fatigue among healthcare professionals are not formally regulated by law. In this matter, hospital management and surgeons need to have a mutual agreement regarding the limits of working hours. Notwithstanding, the sound and solid safety record of aviation has been indisputable and proven itself for decades. These aviation safety concepts will continue to be a useful source of inspiration for any healthcare professional striving to achieve superior patient safety standards.
Limitations
Even though this review article shed light on novel aspects of aviation safety concepts into patient safety in healthcare context, there were some limitations. Because this article is a review article, future study should probably extend the concepts of this review into an experimental research to analyze the effect of those concepts on actual healthcare settings. Additionally, qualitative research may prove useful to investigate the real application of these concepts in actual healthcare context as qualitative study can delve deep down into richer results that quantitative research cannot find.
ACKNOWLEDGEMENTS
The lead author would like to thank my
Conflict of interest:There is no conflict of interest.
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