following is a comparison of the recommendations
stated in the Institute of Medicine’s
(IOM) report entitled “To Err Is Human:
Building a Safer Health System” and
the premises of training by The Center for
Error Management (CEM)
In the Executive Summary, the IOM’s
report cites the death of Ms. Betsy Lehman,
due to a drug overdose during chemotherapy
as a major medical incident. This particular
case is one of the examples of error addressed
by CEM. It is discussed while introducing
one of six human traps and tool kits called
Group Dynamics Management. Specifically, within
this tool kit Betsy suffered from a trap called
“Co-worker syndrome”. It was discovered
that not less than 12 individuals were involved
in the administration of Ms. Lehman’s
overdose; all expecting the others had made
sure the dosage was correct. The report alludes
to other accidents, which it calls “adverse
events” and cites many figures and percentages
to make the point that change is needed, to
which CEM agrees.
Throughout the report, IOM refers to training, simulation,
and safety practices that have been instituted by
the military and commercial aviation industry. The
report suggests the medical field should learn from
these aviation practices and institute similar efforts.
CEM’s thesis of error management is born out
of these same aviation disciplines utilizing aviation
case studies to establish training points.
The IOM report defines an error as “…the
failure of a planned action to be completed as intended
(error of execution) or the use of a wrong plan
to achieve an aim (error in planning)”. The
Center for Error Management addresses these errors
as being a part of everyday life. To understand
human error you have to understand humans are always
present. They are at the planning stage, execution
stage, monitoring stage and finale stage of every
action. The human constantly is in need of evaluating
each stage they are in and be ready to make changes.
The IOM report called it being ready to “expect
the unexpected”. This is what CEM prepares
students to do.
The report discusses many facets of error concerns.
It gives a historical perspective of errors, breaking
them down into categories of equipment failures,
medication application mistakes, patient safety
concerns, congressional responsibilities and ultimately
why all these errors happen. It also addresses the
need for better reporting of errors by the medical
industry and how this will provide for better patient
care. Only through the comparison to the aviation
industry does it address a proactive approach: the
action of being ready and able to foresee possible
dangerous situations or accidents in the making.
This is the goal of The Center for Error Management’s
training program. It is a phenomenon CEM entitles
the “Error Chain”. A chain of events
that must be recognized and broken before the accident,
incident or error is made.
Specifically, chapter eight of the report entitled,
Creating Safety Systems in Health Care Organizations
recommends “…incorporating proven methods
of managing work teams as exemplified in aviation”.
The chapter establishes five specific principles
which health care organizations are suggested to
meet. Each of the principles is followed by a CEM
tool, which can meet the expected criteria. The
1: Provide Leadership.
CEM trains students how to be leaders. To assist
the Leader, CEM has created a “Make it Happen”
Workshop that will introduce Tools forcing teams
to address questions needed to be effective. This
workshop will introduce Tools for the team to use
that will keep situational decision makers apprised
of all necessary data to make sound decisions.
Principle 2: Respect Human Limits in Process
Through the training process, students will understand
human limitations by periodically reviewing the
Traps and Tools introduced by the six tool kits.
Process designers will appreciate the individuals
using the process and constantly evaluate the effectiveness
of the process. Latent errors will therefore be
mitigated through constant process review and awareness.
Principle 3: Promote Effective Team Functioning.
Students learn how teams become a single unit and
the importance of their individual part of the team.
An additional tool called TEBS will promote each
of the team members and allow effective communication
within the team. Authority for all to participate
equally will be addressed. Each will discuss the
Task, Equipment, Barriers, personal Skills needed
to complete a mission as it is intended.
Principle 4: Expect the Unexpected.
Tools will be introduced allowing team members to
monitor the process throughout any task application.
When “unexpected” events occur the “expected
action” will take place through use of a tool
called QPIDR. The event will be Questioned. The
Promotion of Ideas will take place. A Decision will
be made. The event will then be monitored through
a Review process until completion.
Principle 5: Create a Learning Environment.
The training process is designed to be a continuous
review of The Center for Error Management’s
premise of error management. It will surface needed
changes in standard operating procedures; it will
identify equipment anomalies; it will identify the
required skill level of each person on the team;
it will make sure the team is capable and ready
to complete the task as intended. Tools will also
be available to assist in the implementation of
an error management culture.
The Center for Error Management is quite different
from other human factor efforts in that humans are
recognized as the creator of systems, processes,
and machines. Only humans can evaluate the readiness
and correctness of each. CEM also understands that
psychological, emotional, and physiological factors
affect human readiness. It is those factors students
need to accept and be able to counteract. In short,
CEM desires to make all individuals and teams accountable,
responsible and effective.
- Larry Foss
Center for Error Management 2004-2011