Intensive care medicine: More safety thanks to aviation knowledge
Intensive care medicine: More safety thanks to aviation knowledge
Interview with Hans Härting, Managing Director of AssekuRisk Safety Management GmbH, and Dr. Jens-Christian Schwindt, Managing Director of SIMCharacters Training GmbH
What do intensive care medicine and aviation have in common? In both fields, mistakes can quickly put people’s lives at risk. That’s why high safety standards should be a matter of course for both. Having said that, medicine lags behind by comparison because staff members often lack the opportunities to train for emergency situations and the proper tools to prevent patients from being harmed.
As part of their keynote lecture at the 2017 Annual Congress of the German Interdisciplinary Association of Intensive Care and Emergency Medicine (DIVI), Hans Härting and Dr. Jens-Christian Schwindt explained how cockpit insights on training, teamwork, and safety can benefit the intensive care unit and emergency medicine. MEDICA-tradefair.com asked them about these aspects.
Mr. Härting, Dr. Schwindt, what can critical care physicians learn from aviation?
Hans Härting: For the past 20 to 30 years, aviation operations specialists have been legally obligated to participate in academic training in human factors and teamwork at regular intervals. This is not the case in the medical sector. Secondly, the aviation industry has a strong standardization of processes, which is absent in medicine and thus promotes error occurrence. Thirdly, in aviation, we prepare for specific situations using a simulator, while physicians learn from actual emergencies once they treat the patient.
What does the term "human factors" mean exactly?
Härting: It refers to the non-technical skills and human aspects that pertain to a person's awareness and responses to situations. "Human factors" is the area that acknowledges human fallibility and circumstances. There are limits to people's perceptual, cognitive and physical abilities; everyone gets tired at some point and affected by emotions. This needs to be addressed to illustrate that a zero error policy is something that is unrealistic.
The medical field still looks down upon and disapproves of safety tools that have been tried and tested in other systems such as checklists, closed-loop communication or briefings for instance. Medicine and aviation are drastically different in their cultures. In medicine, we concede that errors cost time and money but we neither spend time nor money to train teams, take them into a simulator and debrief them afterward.
Dr. Jens-Christian Schwindt
Dr. Jens-Christian Schwindt: We also must accept that we make mistakes in medicine and we have to learn to admit them. We quickly cause patients harm because we do not have extensive safety barriers in place that prevent an error from turning into injury and harm. Aviation always anticipates errors, which is why there are safety barriers. These "safety barriers" such as briefings and the use of checklists can also be used effectively in medical science and improve patient safety.
Where do you see actual parallels between intensive care medicine and aviation?
Härting: Medicine is far more complex than aviation and has developed different strategies to prevent errors. However, both fields require staff members who work well together. This issue is also not primarily about medical errors but rather mistakes made in logistics, in the process that leads to patient harm.
For example, in the aviation field, every pilot repeats instructions he receives from the controller as an acknowledgment and for control purposes. That is to say, he obtains a confirmation before he executes the instruction. In intensive care medicine, it is difficult to encourage teams to adhere to this type of process because team members lack the necessary mindset. Meanwhile, safety is primarily a question of mental attitude and mindset. This is why we need a safety culture versus an error culture. Safe conduct has to be cultivated but to do this, there needs to be an appreciation for the use of safety tools like checklists. This is an absolute given in aviation but in medicine, it is an almost impossible feat because the staff does not have time for it or feels offended or patronized on a professional level.
Schwindt: Initially, there needs to be a mindset shift in medicine, which is quicker and somewhat easier to accomplish than a change in culture. Medicine also first needs to develop an understanding of the use of safety tools like checklists that ostensibly take more time. Ultimately, an improvement in patient safety always translates into an improvement in employee safety. After all, as health professionals, we are always the second victim if something happens to a patient. And here we always want what’s best for our patients.
Learning from aviation: There are many safety barriers in the organization of the cockpit that are designed to protect people from damage.
What should a human factors training look like to elicit a response from health professionals and trigger a shift in culture?
Härting: It is essential to clear up the misconception that checklists are an insult or demonstrate patronizing or condescending behavior towards staff members. The training objective is to create awareness and understanding of these tools that are designed to prevent harm to patients and employees. In 2014, the New England Journal of Medicine published a study that registered no effect of checklists, as long as staff members have a negative attitude towards them and no training.
Our work with hospitals has shown that senior management has to support these types of measures one hundred percent because it otherwise neutralizes the effect of the training intervention. This is the only way to ensure that people understand the importance of standardizing, simplifying and safeguarding logistical processes. After the training, staff members subsequently have to acknowledge the basic philosophy and the goal to foster structured interactions, to flatten hierarchies and to create a climate in which they can address what they perceive. Only then can you develop standardized processes that are – for the most part- still lacking in medicine.
Schwindt: Nursing staff and physicians would love to train but often do not get the time to do so. I believe that ultimately this process will only work if it mirrors how things are handled in aviation: the legislator dictates how often these types of training need to be conducted and withdraws the hospital’s operating permits for areas where this is not accomplished.
What feedback do you get from this approach?
Schwindt: For example, nursing staff, midwives, and physicians in neonatology provide excellent feedback after our emergency training sessions. They say, "I now feel more confident and safer." This is great both for patients because they are more likely to receive better emergency care and for staff members, who feel better prepared to handle the situation. Medical staff wants to train and be great at their jobs because we always feel responsible for what we do, especially when things go wrong sometimes. Having said that, in most instances, the main culprit is not the individual who made the mistake but rather a poor infrastructure, ineffective processes and lack of training.
Härting: The people we train are very grateful for the instruction. Unfortunately, many hospitals still lack the motivation to provide human factors training or emergency management training. Today, hospitals spend a lot of money on quality management and certification. However, not much of that reaches the patient in actual practice. Quality management is vital and processes must be regulated. However, the most important aspect is the actual strategies staff members use to prevent patient harm on an everyday basis or to manage emergency situations. This is when they are often left to their own devices. The aviation sector has done its homework in this regard. The safety is reflected in the results. The medical field can still learn something from this aspect.
The interview was conducted by Timo Roth and translated from German by Elena O'Meara. MEDICA-tradefair.com