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

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 149; no. 2; pp. 496 - 507.e4
• Main Authors: Hickey, Edward J., MD, Nosikova, Yaroslavna, MSc, Pham-Hung, Eric, BSc, Gritti, Michael, BSc, Schwartz, Steven, MD, Caldarone, Christopher A., MD, Redington, Andrew, MD, Van Arsdell, Glen S., MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.02.2015
• Subjects: aviation; Cardiac Surgical Procedures - mortality; Cardiothoracic Surgery; error; Humans; Medical Errors - prevention & control; Medical Errors - statistics & numerical data; Pediatrics; resource management; Risk Assessment - methods; Risk Factors; threat; United States; United States National Aeronautics and Space Administration; United States; resource management; 44; ECMO; risk adjustment for congenital heart surgery; OR; NASA; FAA; aviation; crew resource management; odds ratio; error; LOSA; Federal Aviation Administration; line operation safety audits; National Aeronautics and Space Administration; extracorporeal membrane oxygenation; threat; 41; RACHS; 20; 21; CRM
• ISSN: 0022-5223; 1097-685X
• DOI: 10.1016/j.jtcvs.2014.10.058

Abstract Background 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. Methods 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. Results 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 occurred. Cycles, particularly those containing multiple errors, were very significantly associated with permanent harmful end-states, including residual hemodynamic lesions ( P  < .0001), end-organ injury ( P  < .0001), and death ( P  < .0001). Deaths were almost always preceded by cycles (6 of 7; P  < .0001). Conclusions Human error, if not mitigated, often leads to cycles of error and unintended patient states, which are dangerous and precede the majority of harmful outcomes. Efforts to manage threats and error cycles (through crew resource management techniques) are likely to yield large increases in patient safety.