Improving Patient Safety In Rural Hospitals

Establishing a Culture of Safety

Presenters: David Musson, M.D., University of Texas Human Factors Project, University of Texas at Austin, TX. Terrance Borman, M.D., Medical Director, Luther-Midelfort, Mayo Health System, Eau Claire, WI.

Research Summary

Dr. David Musson of the Human Factors Research Project at the University of Texas, Austin (UTHFRP) discussed establishing a culture of safety in aviation and how approaches taken in aviation might be translated to health care.

The UTHFRP has focused on aviation in relation to medicine since 1993, before the release of the 1999 Institute of Medicine report, To Err is Human. That report emphasized that many medical errors are attributable to systems failures and the health care system should recognize that unintentional human factors play a large role in the formation of the system. The aviation industry has a long history of reducing error at they system level and has made safety a "super-ordinate" goal, according to Musson. Similar to medicine, teamwork is essential in aviation, risk level varies from low to high, and threat and error come from multiple sources.

The UTHFRP addresses medical errors using an aviation approach, including a system approach to system error, organized development of error countermeasures, and ongoing research and data collection in support of safety. Aviation's countermeasures for enhancing safety includes:

• Crew resource management (CRM). Involves training in leadership, communication, and information management.
• Automation. Automation was introduced for the purpose of improving safety, and has been effective, according to Musson, but has also presented new types of unanticipated errors.
• Standardization. Standardized training, standard operating procedures, and the use of checklists have all been implemented in the aviation industry to reduce variation and likelihood of error.
• Data collection for safety improvement. Two incident reporting systems, the Aviation Safety Reporting System (ASRS) which is system wide and the Aviation Safety Action Partnership (ASAP) which is carrier specific, are used to record and track erroneous incidents and provide a background for improving them in the future.

Musson stressed that data collection is crucial in developing any strategy to reduce errors. In addition to the ASRS and the ASAP, the UTHFRP has collected data on behavior, attitudes and cultures in aviation safety through the use of multiple methodologies, including surveys as well as direct observations of human behaviors. In repeatedly administering the Flight Management Attitudes Questionnaire (FMAQ), researchers found:

• A general improvement in crew resource management related attitudes over the years.
• A unique profile of attitudes for each airline.
• An improvement by specific airlines between successive FMAQs.
• National variation in terms of power distance and automation preferences.

UTHFRP researchers also studied human behavior through the Line Operations Safety Audits (LOSA) program. LOSA involves in-cockpit observations and interviews, non-jeopardy assessments, collecting demographic information, rating CRM and error management behavior, and threat assessment. As a result of the LOSA study, researchers found:

• Automation errors are the most common, yet are hard to observe and insidious.
• Violation of standard operating procedures are common and often inconsequential.
• Crew members have high levels of proficiency.
• Variation exists between carriers with respect to adherence to standard operating procedures, stable approach bottom lines, and cockpit structure.

Musson explained that data collection is one way to begin to address the problem of medical errors in the health care system. In addition to data, he recognized that culture change is a necessary step as well. Musson presented the following model for implementing change in high-risk organizations such as aviation and medicine. He asserted that such a model could be applied within health care to address medical errors:

1. Conduct an initial assessment through:
   1. Interviews.
   2. Surveys.
2. Collect data through:
   1. Error reporting systems.
   2. Focused surveys.
   3. Non-jeopardy observations.
3. Design and implement strategies such as:
   1. Culture change.
   2. Human factors training (such as crew resource management).
4. Assess the impact of interventions through:
   1. Outcomes analyses.
   2. Surveys of practitioners.
5. Maintain iterative modification and implementation of strategies through:
   1. Performance appraisal and feedback.

Dr. Terrance Borman, Medical Director of the Luther Midelfort Hospital of the Mayo Health System, explained how his hospital responded to the national health care priority of addressing patient safety. Luther Midelfort is a 310 bed hospital in Eau Claire, Wisconsin. Due to the impetus started by a 1991 article in the New England Journal of Medicine, "Incidence of adverse events and negligence in hospitalized patients" (Brennan, 1991), the Institute of Medicine's 1999 report, To Err is Human (IOM, 1999), and the 2001 publishing of the Joint Commission standards, Luther Midelfort began to take note of its own adverse events and safety culture.

Borman explained that Luther Midelfort developed a cultural commitment to quality by dedicating time, training, and resources to patient safety. It connected itself with groups such as Mayo Rochester, the Institute for Healthcare Improvement, and the Institute for Safe Medication Practices. It also committed to taking an honest appraisal of the hospital's safety outcomes.

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