Managing threat and error to increase safety in medicine
The topic of patient safety has been of great concern since the release of a report by the Institute of Medicine (IOM) concluding that as many as 98,000 patients per year may die needlessly in the United States as a result of medical error. The patient safety movement has subsequently grown worldwide, although the extent of patient harm internationally is not well established. One recommendation of the IOM report was to adopt the proactive safety strategies of aviation. The University of Texas Human Factors Research Project is investigating human performance and human error in both domains and has adapted a conceptual model of threat and error management from aviation to medicine. The model defines threats at the system, organizational, and professional levels, as well as risks deriving from known and unknown factors associated with patient condition. Medicine is necessarily an interpersonal endeavour that requires communication and co-ordination among people of differing background and status. The inevitability of error as a result of human limitations is noted. Strategies to minimize threats and to manage errors are discussed: including research into cultural factors, using research for cultural change, reporting systems to allow learning from close calls, and training in communications, leadership, and situation assessment, and establishing a safety culture.
