Ever made a mistake? The role of aviation-style error management in healthcare

Abstract

Human error is inevitable in all walks of life. It generally has little effect, unless you work in a safety-critical industry. Aviation and healthcare are two such industries although they have very different approaches to managing error. They also have very different outcomes regarding mortality/morbidity related to error. This paper discusses how aviation achieves these results and how they could be transferred to healthcare. Aviation has a three-stage approach to managing error. First, we have a “Just Culture” which means we can own up to genuine mistakes without fear of disciplinary action or sanctions as long as we cooperate with investigating how the error occurred. It is not a “No-Blame” culture; we are still expected to take responsibility for our actions. Second, we investigate each event to find why the error occurred. We usually identify a “tripwire” which led to the individual making the error. We assess whether we can re-engineer the system to remove the tripwire and, if possible, add a safety net to reduce the chance of recurrence. Third, we train staff in error management as part of both initial training and recurrent training. Aviation globally is now focussing on introducing evidence-based training to better meet the needs of the crew and make most effective use of expensive training time. These principles are relevant and transferable to healthcare and could potentially be equally successful there. Success, however, relies on a change in culture by both staff and patients. Error needs to be accepted as inevitable in healthcare, as it is in aviation, and that the outcome is determined by how it is managed. We need to focus on “what went wrong” as opposed to “who went wrong” and accept that attributing blame and demanding retribution is not a sustainable approach.