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

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...