A cockpit checklist to improve patient safety

Originally published in MedPage Today

by Chris Emery, MedPage Today Contributing Writer

Medical teams should take a lesson from airplane crews, a new study concludes.

Medical personnel who used procedural checklists modeled after preflight checklists used by airplane crews were more likely to report safety-related incidents and feel empowered to address safety issues, according to an online report in the Dec. 21 Archives of Surgery.

After preoperative checklists were introduced to certain medical teams, their use rose from 75% in 2003 to 100% in 2007, the study found.

The introduction of checklist-based programs, known in the aviation industry as “crew resource management programs,” or CRMs, was accompanied by an increase in self-initiated reports of safety breaches among medical staff, from 709 per quarter in 2002 to 1,481 per quarter in 2008 among teams using the checklists.

“The introduction of CRM training, combined with other initiatives, enhances personal commitment to patient safety and appears to alter behaviors relative to checklist use and self-reporting,” Harry C. Sax, MD, of the Warren Alpert Medical School of Brown University, and colleagues wrote. “Participants become aware of, and empowered, by these tools.”

With patient safety now a central theme in American medicine, the medical community has turned to the aviation industry for ideas. CRMs, developed in the late 1970s after the collision of two 747 airliners on a foggy runway in Tenerife, have helped make flying the safest form of transportation on a per-mile basis.

The programs focus on both human and systems issues, improving communication, error management, and work culture. In recent years, hospitals have invested in CRM-based training for their staff, usually beginning in high-risk areas such as the emergency department, obstetrics/gynecology, and surgery.

In the study by Sax and colleagues, 857 medical staff at Strong Memorial Hospital of the University of Rochester (50% nurses, 28% ancillary personnel, 22% physicians) participated in such courses from 2003 to 2006.

Beginning in 2005, an additional 349 staff attended the same course at Miriam Hospital, a teaching hospital in Providence, R.I. associated with with Brown University.

The program included a regularly scheduled six-hour course called “Lessons from the Cockpit,” developed with the chief medical officer, chief safety officer, nurses, anesthesiologists, a surgeon/general aviation pilot, and Indelta Learning Systems, an educational training company that applies CRM concepts to nonaviation industries.

The course used videos, team-building exercises, and open forums to educate personnel on the concepts and procedures.

Before and after the courses, researchers tracked preoperative checklist use and the number and type of entries on a Web-based incident reporting system available to the personnel. They also measured participants’ degree of empowerment on a 10-point survey of safety attitudes and actions.

In addition to finding that use of the checklists and incident reporting system increased over time, the researchers found that immediately after the training, the perceived self-empowerment among the participants rose by an average of 0.5 points on a five-point scale in all 10 areas addressed by the survey (P<0.05). The perception persisted for at least two months. However, they also found a trend towards participants being more uncomfortable confronting physicians about lapses in safety than confronting nurses or technicians (P>0.05).

“Not surprisingly, there was initial resistance because surgeons saw the checklists as speed bumps that hindered flow,” the authors wrote.

“The circulating nurse was then empowered to start the checklist process and the scrub nurse was instructed not to hand up the knife until the checklist was completed. Hospital administration and all clinical chiefs were broadly supportive of this process, and any physician who was unwilling to participate was counseled.”

The authors noted that participant behavior, such as self-reporting of incidents, could have been influenced by other safety initiatives in the hospital. They also cautioned that their survey was locally developed and was not validated, with participation of only 80% at the time of the course and 40% at the two-month follow-up.

Furthermore, they noted, surveys conducted close to the time of a training session typically show a positive response.

Still, based on the results, they concluded that CRM-like programs could help reduce medical errors.

“Leadership of institutions must strive to foster the elusive ‘culture of safety’ by creating an environment that focuses on systems issues as opposed to individual blame, maintains personal accountability, and encourages open communication in a supportive environment across all disciplines,” they wrote.

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