Abstract
Failure to rescue is now a commonly used term in healthcare, and describes the likelihood and ability of a team or providers to recover a patient from actual or impending harm. It can be used as a metric of performance for clinical teams and individual clinicians, but does require robust benchmarking to determine acceptable standards of care and expectations, as well as risk adjustment for patient populations, procedures and complexity. The key principles of effective threat and error management are anticipation, recognition and recovery. As outlined here, high-stakes industries with exemplary safety records exhibit a preoccupation with possibility of failure. They promote a culture of continuous vigilance, communication and problem-solving, and expect personnel to make errors but embrace non-punitive reporting to understand the root cause of threats and errors. They train their workforce to predict and prevent loss of situational awareness. We propose that a more meaningful metric of the performance of teams and providers is one that describes the failure to perceive an evolving clinical state, in addition to the ability to rescue patients once an event has occurred.
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Notes
- 1.
For confusing reasons that relate to long-term process iteration models, 6σ actually correlates statistically to 4.5 standard deviations and hence 3.4 events per million, or an event rate of 0.00034 %. Commerical aviation exceeds this quality metric. The top paediatric heart surgery centres currently function at ~3.5σ in terms of patient mortality (about 3 %).
- 2.
The press seems comfortable with the phrase and concept of “pilot error” as a frequent factor in air accidents. Simple online searches for surgical error lead to national newspaper headlines describing “scandals” of “bungling surgeons”, “botched operations” and “baby killers”.
- 3.
Icing of a pitot tube led to brief and transient loss of air speed data and autopilot disengagement. The crew responded with some inappropriate manual flight control inputs which led to an escalation of unintended states, errors and increasingly unstable flying configurations. The crew became increasingly confused and disbelieving of the instruments. Task-sharing and coordination of roles was poor and even at the point of impact two pilots were attempting to make opposite manouvres with the side-sticks.
- 4.
In 1977, Captain Veldhuyzen van Zanten – KLM’s most senior captain – powered up his 747 and trundled down the runway at Tenerife without ATC clearance. The young engineer in the cockpit realised that a taxiing Pan Am 747 may still be on the runway, and asked rhetorically whether clearance had been given. The captain cut him short and asserted that things were fine. They were not fine; the two planes collided with what remains to this day the biggest loss of life in any air accident. Ironically, Captain van Zanten was held in such high regard as a pilot by KLM’s executive that upon hearing about the crash they immediately sought him to lead their investigation, only to discover that he was the captain involved. The Tenerife disaster was one of a number of high profile air crashes in the 1970s and 1980s that highlighted the dangers of a traditional steep hierarchy.
- 5.
US Airways flight 1549 successfully landed in the Hudson River after a double bird strike shortly after take-off. British Airways flight 38 lost thrust on both engines at an altitude of 720 ft during the final approach to Heathrow and crash-landed 890 ft short of the runway. There was no loss of life in either accident and both crews were praised for their CRM skills during the crises.
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Hickey, E.J., Van Arsdell, G.S., Laussen, P.C. (2015). Failure to Rescue and Failure to Perceive in Pediatric Cardiac Surgery: Lessons Learned from Aviation. In: Barach, P., Jacobs, J., Lipshultz, S., Laussen, P. (eds) Pediatric and Congenital Cardiac Care. Springer, London. https://doi.org/10.1007/978-1-4471-6566-8_13
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