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Human Factors and Culture

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✱ The Goal of this project has been to develop a model of error in the medical environment. ✱ Our experience in aircraft accident investigation has demonstrated the utility of such a model in identifying threats, errors, and opportunities to mitigate error. ✱ Our belief is that a model specific to medicine could prove useful to the understanding of the nature of error and its management in this somewhat more complex environment.
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  • Tags: analyze events, define training needs, recognize and manage threat and error
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The University of Texas
Threat and Error Management Model:
Components and Examples
Robert L. Helmreich Ph.D.
David M. Musson, M.D.
Department of Psychology
The University of Texas at Austin
Published on the British Medical Journal Web Site (www.BMJ.com)
At: http://www.bmj.com/misc/bmj.320.7237.781/
University of Texas
Human Factors
Research Project

Notes
Robert L. Helmreich is Professor of Psychology, The University of Texas
at Austin and Director, University of Texas Human Factors Project.
The work reported was supported in part by a grant from the Carl
Benz und Gottlieb Daimler Stiftung. Correspondence to Robert L.
Helmreich, Department of Psychology, The University of Texas at
Austin, Austin, TX 78712, U.S.A. helmreich@psy.utexas.edu
David M. Musson is a physician and a doctoral student in Psychology at
the The University of Texas at Austin. He is supported by a Fellowship
from the Medical Research Council of Canada.
Musson@mail.utexas.edu
Project Website: www.psy.utexas.edu/psy/helmreich/nasaut.htm

A Model of Medical Error
The Goal of this project has been to develop a model of
error in the medical environment.
Our experience in aircraft accident investigation has
demonstrated the utility of such a model in identifying
threats, errors, and opportunities to mitigate error.
Our belief is that a model specific to medicine could prove
useful to the understanding of the nature of error and its
management in this somewhat more complex environment.

Why Develop Such a Model?
To analyze adverse events
To define training needs for medical personnel
To define organizational strategies to recognize and
manage threat and error

Specific Application of the Model
Ideally, a model of the error process in medicine should
aid identification of:
1 the types of errors committed
2 deficiencies in training and knowledge
3 ineffective, lacking or potential error detection strategies
4 effective error mitigation or management strategies
5 threat detection and management strategies
6 systemic threats

A Model of Threat and Error in the Medical
Environment
An effective model should:
– Capture the context of patient treatment including expected and
unexpected threats
– Classify the types of threats and errors that occur in the medical
setting
– Classify the processes of managing threat and error and their
outcomes
– Lead to identification of latent systemic threats in the medical
setting

Definitions
Threats - factors that increase the likelihood of an error
being committed - these may be environmental (such as
lighting), physician-related (fatigue), staff-related
(communication), or patient-related (a difficult intubation).
Latent Threats - aspects of the hospital or medical
organization that are not always easily identifiable, but that
predispose the commission of errors or the emergence of
overt threats (call schedules and health policies, for
example).

Definitions - 2
Error types – as in the University of Texas Aviation Threat
and Error Management model, we have classed errors with
the following taxonomy:
» Communications errors
» Procedural errors (knowing what to do, but getting it wrong)
» Proficiency errors (not knowing what to do)
» Decision errors
» Violations of formal policies or procedures
Threat and error management behaviors - actions taken
by the medical team to reduce threat or manage error
– Vigilance and monitoring
– Effective decision making, etc.

Overall Structure of the Model
Latent threats - what exists in the organization?
Overt threats - what was present that day?
Human Error - what was done wrong?
Error management - how was the mistake handled?
Outcomes - did a change in a patient’s well being
result from the error, and how was it managed?

Components of the Model
Latent Systemic
Threats
Overt threats
and patient factors
Error
Error
Management
Outcomes
Behaviours

Document Outline

  • The University of Texas Threat and Error Management Model:Components and Examples
  • Notes
  • A Model of Medical Error
  • Why Develop Such a Model?
  • Specific Application of the Model
  • A Model of Threat and Error in the Medical Environment
  • Definitions
  • Definitions - 2
  • Overall Structure of the Model
  • Using the Model
  • Using the Model (2)
  • The Threat and Error Components
  • We can combine these two components, producing the full model of threat and error management...
  • Using the model to examine a complex incident...
  • The Case
  • Synopsis of the Event
  • Synopsis - continued
  • Synopsis - continued
  • It is possible to identify at least 9 discrete errors committed during the operation. We will conduct a full analysis of two o
  • Summary of Sequential Medical Errors
  • Each error may be analysed separately using the Threat and Error Management Model
  • First we will examine error #1 - the decision to proceed without connecting the temperature probe to the temperature monitor.
  • Analysis with the model suggests the following latent factors are relevant to the management and outcome of this particular er
  • Safeguards and interventions suggested by the analysis of error #1:
  • Further analysis...
  • Analysis with the model suggests the following factors are relevant to the management and outcome of this particular error (er
  • Safeguards and interventions suggested by the analysis of error #4:
  • A full analysis...
  • Some overt and latent threats identified in this case:
  • A Cautionary Note...

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