Adaptation of Airline Crew Resource Management Principles and Checklists to Dentistry. Mark Pinsky DDS 29 May 2015

Transcription

1 Adaptation of Airline Crew Resource Management Principles and Checklists to Dentistry Mark Pinsky DDS 29 May 2015

2 Mark Pinsky DDS DDS The Ohio State University 1983 General Practice Residency Einstein Hospital Philadelphia 1984 Delta Airlines International A-330 Captain

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5 UMSoD Leadership Pathway Project Tyler Eatchel D3 IRB Exempt University of Michigan HUM Please fill out Looking for any error experiences you have personally done at anytime in your career, or have seen anyone else do

6 Risk Fly a Plane or Perform Dental Procedure Walk Across a Street Sleep (OSA) & Eat (Heimlich) Can Not Escape Only Manage Tacitly Understood Basis for Adaptation of CRM to Dentistry

7 Risk Management Continuous Loop Incorporating: Past Present Future

8 Management of human element is the single most important key to risk management because it is the one risk factor category that can cause a dentist to ignore all the other risk factors /$FILE/Chap%204-appendix.pdf

9 Expert Characterized by close to error free performance in domain specific tasks Chi Glaser Fare 1988 Building Expertise: Cognitive Methods for Training and Performance Improvement- Hillsdale NJ Lawrence Erlbaum Associates

10 Domain Specific Expert Rolls Royce Cars --- Yes Pizza --- No Dental Composite Manufacturer Composite --- Yes Pacemaker--- No Dentist Oral Cavity is Domain Specific area of expertise

11 Efficiency Paradox Increased Repetition = Increased Proficiency = Increased Efficiency = Increased Safety Increased Repetition = Increased Exposure = Increased Risk = Decreased Safety

12 How Many Steps in a Procedure? Miller s Law objects in working memory 7 +/- 2 Psychol Rev 1956 Mar;63(2): The magical number seven plus or minus two: some limits on our capacity for processing information. Miller GA

13 243 Errors in Fabrication of RPD Human Error is Inevitable

14 Prospective Memory the cognitive process involved in remembering or forgetting to perform actions to be performed at a later time Deferred intention Called to pick up dry cleaning at 1300, Forget by 1700 Juggling several items during a procedure involves a momentary prospective memory Called Concurrent Demands The Multitasking Myth- Dr. R. Key Dismukes

15 Memory Terms Short Term Memory Long Term Memory Continuous Partial Attention Absent Mindedness Attention Management

16 DAYDREAMING Non Task Related Thought

17 Human Error is Inevitable Mulhouse-Habsheim Airport, France

18 Human Error is Inevitable BQVs-nBKM%3A%3BC5xGUeQ3tpweZM%3Bhttp%253A%252F%252Fwww.endoexperience.com%252Fimages%252FJanCase.jpg%3Bhttp%253A%252F%252Fwww.endoexperience.com%252Fpro_caseJan01.html%3B250%3B197

19 Human Error is Inevitable

20 Human Error is Inevitable

21 Human Error is Inevitable

22 Human Error is Inevitable Marini et al, OOO v115;5 May 2013

23 The removal of a malpositioned implant in the anterior mandible using piezosurgery Marini E, Cisterna V, Messina A; Volume 115 Issue 5, May 2013, Pages e1 e5 8/19 references Near-fatal airway obstruction after routine implant placement Life-threatening hemorrhage from placement of a dental implant Life-threatening oral hemorrhage after implantation into the distal right mandible Hemorrhage of the floor of the mouth resulting from lingual perforation during implant placement: a clinical report Hemorrhage in the floor of the mouth after second-stage surgery: case report Important arterial supply of the mandible, control of an arterial hemorrhage, and report of a hemorrhagic incident Excessive bleeding in the floor of the mouth after endosseus implant placement: a report of two cases Assessment of nerve damage using a novel ultrasonic device for bone cutting

24 JADA May 2015 Human Error is Inevitable

25 ~96% Success? No peri-implantitis? No Bone loss? No Discomfort? In Function? Lost to follow up? Airplane Flight? P. Papaspyridakos et al, J Dent Res 91(3): , 2012

26 Absolute Failure is not the only Measure!!!! 38.7% of all implant-supported fixed partial dentures (FPD) for partially edentulous patients had some type of complication Pjetursson et al., 2007 JDR

27 Error To err is human Any Action or Inaction that leads to an UNEXPECTED OUTCOME Error is best mitigated prospectively

28 (Very) Basic Error Theory Omission or Commission Rasmussen & Jensen Skill Based - Automatic Slips Rule Based - Mistakes Knowledge Based - Most Complex Reason Latent Accident waiting to happen Active Effect seen immediately Leape LL. Error in medicine. JAMA 1994;272(23):

29 Error

30 End State Comes After Threats / TEM Error / EM Undesired states End State Irreversible End State

31 End State Error Marini et al, OOO v115;5 May 2013

32 Root Cause Analysis Traditional components 1. Tooth / Oral Cavity / Patient 2. Restorative Material / Treatment 3 rd component Performed by a Human (Team)

33 Normalization of Deviance

34 Normalization of Deviance

35 Situational Awareness Perception of the elements in the environment within a volume of time and space (PAST) Comprehension of their meaning (PRESENT) Projection of their status (FUTURE) Endsley, M.R. (1988). Design and evaluation for Situation Awareness enhancement. IProceedings of the Human Factors Society 32nd Annual Meeting (Volume 1, pp ). Santa Monica, CA: Human Factors Society human_factors/situational_awareness/knowing_what_is _going_on_around_you-e.html

36 Situational Awareness

37 Situational Awareness

38 SA

39 Situational Awareness (SA) Factors That Reduce SA Insufficient Communication Fatigue / Stress Task Over Load Task Under Load Group Mindset "Press on Regardless" Philosophy Degraded Operating Conditions

40 Which Dentist Would You Choose?

41 S A ll- MbbFlgF6trrZ0nD5ZbYK9aDs=&h=1536&w=2048&sz=487&hl=en&start=0&sig2=Xq5-wInXi4ZoSm08-bT2EQ&zoom=1&tbnid=MTZ0vVjOda1p6M:&tbnh=137&tbnw=181&ei=oTE8TchHYXUgQfOz6HdCA&prev=/images%3Fq%3Dindia%2Bdentist%26hl%3Den%26safe%3Doff%26sa%3DG%26biw%3D1131%26bih%3D775%26gbv%3D2%26tbs%3Disch:1,isz:l&itbs=1&iact=rc&du r=197&oei=eje8tadsaya8lqe_ptnpbg&esq=5&page=1&ndsp=20&ved=1t:429,r:4,s:0&tx=112&ty=78

42 S A pejjj7lrq2nrfnxkaazvj5x biyw=&h=768&w=1024&sz=128&hl=en&start=0&sig2=hax8xtwcvco7_-1fkiqzfa&zoom=1&tbnid=4clyrfl- VlC8IM:&tbnh=133&tbnw=177&ei=0C88Tbq2NMKclgfQ2Ki9Bg&prev=/images%3Fq%3Ddental%2Bexam%26hl%3Den%26safe%3Doff%26sa%3DG%26biw%3D1131%26bih%3D775%26gbv%3D2 %26tbs%3Disch:1,isz:l&itbs=1&iact=hc&vpx=829&vpy=145&dur=7062&hovh=194&hovw=259&tx=201&ty=160&oei=0C88Tbq2NMKclgfQ2Ki9Bg&esq=1&page=1&ndsp=23&ved=1t:429,r:5,s:0

43 S A IN7UTsqqSPNltx1SWzIF6RWuA3E=& h=2000&w=3008&sz=2773&hl=en&start=94&sig2=lyud72damhnpkvytqzkc3a&zoom=1&tbnid=lpuahgwzyzxtdm:&tbnh=136&tbnw=180&ei=qs88tzr6bolzgaf2pjcfca&prev=/images%3fq %3Ddental%2Bhistory%26hl%3Den%26safe%3Doff%26sa%3DG%26biw%3D1131%26bih%3D775%26gbv%3D2%26tbs%3Disch:1,isz:l0%2C2325&itbs=1&iact=hc&vpx=813&vpy=481&dur=6532& hovh=183&hovw=275&tx=196&ty=126&oei=ny48te-fc4eglafshq3zbg&esq=2&page=5&ndsp=24&ved=1t:429,r:11,s:94&biw=1131&bih=775

44 S A

45 S A 003_Lt._Ray_S._Hovijitra_of_Indianapolis_and_his_assistant,_Dental_Technician_Donald_Fulcher,_from_Portland,_Ore.,_perform_a_dental_exam_on_a_Sailor_aboard_USS_Kitty_Hawk_(CV_63).jpg&imgrefurl= 003_Lt._Ray_S._Hovijitra_of_Indianapolis_and_his_assistant,_Dental_Technician_Donald_Fulcher,_from_Portland,_Ore.,_perform_a_dental_exam_on_a_Sailor_aboard_USS_Kitty_Hawk_(CV_63).jpg&usg= IQfC7KlIk9dqcYzNpk_abXcWIVg=&h=1312&w=2000&sz=1630&hl=en&start=23&sig2=ZsIDXw6_lbKE715GOZHsQw&zoom=1&tbnid=sEy01GfDJCxGdM:&tbnh=131&tbnw=175&ei=bjA8 Tce8LNT3gAeL- ImlCA&prev=/images%3Fq%3Ddental%2Bexam%26hl%3Den%26safe%3Doff%26sa%3DG%26biw%3D1131%26bih%3D775%26gbv%3D2%26tbs%3Disch:1,isz:l0%2C581&itbs=1&iact=hc&vpx=6 77&vpy=338&dur=8383&hovh=182&hovw=277&tx=198&ty=103&oei=0C88Tbq2NMKclgfQ2Ki9Bg&esq=2&page=2&ndsp=20&ved=1t:429,r:8,s:23&biw=1131&bih=775

46 Threat Anything that increases the complexity of a situation May be Obvious Unexpected Latent Not obvious or observable Uncovered by data analysis washingtonrebel.typepad.com Merritt A, Klinect J. Defensive Flying for Pilots: An Introduction to Threat and Error Management. The University of Texas Human Factors Research Project. The LOSA Collaborative. Dec. 12, publications/pubfiles/tem.paper pdf. Accessed July 5, 2010

47 Threat

48 Threat

49 Threat _e0bdh4dl6h2ua&usg= mhrb5a_tfatui6gnhbxscsy5yzc=&h=854&w=1223&sz=118&hl=en&start=114&sig2=ax1e9oqt8pve8efsw5enfq&zoom=1&tbnid=wimysdikmgmzxm:&tbnh=131&tbn w=190&ei=byw8tbvflpsugqffrd2ca&prev=/images%3fq%3dcarious%2bteeth%26hl%3den%26safe%3doff%26biw%3d1131%26bih%3d775%26gbv%3d2%26tbs%3disch:1,isz:l0%2c3604&itbs=1&iact=hc&vpx=127&vpy=13 3&dur=9974&hovh=188&hovw=269&tx=212&ty=74&oei=WCw8TYCdB4G8lQfnpfXWBg&esq=6&page=6&ndsp=22&ved=1t:429,r:17,s:114&biw=1131&bih=775

50 Threat Courtesy Dr. D Sarment

51 Threat Courtesy Dr. D Sarment

52 Threat

53 Threat Data Overload

54 Threat

55 Threat and Error Management

56 Threat and Error Management Managing Error is managing the PAST (Intervention) Managing Threats is managing the FUTURE (Prevention)

57 Threat and Error Management TEM Philosophy Anticipation Recognition Recovery Planning of Countermeasures Execution of Countermeasures Review / Modify Countermeasures

58 Threat & Error Management Swiss Cheese

59 Changing the Intervention Point 1 Accident 30 Reported 300 Unreported

60 Safety Dictionary the condition of being safe from undergoing or causing hurt, injury, or loss

61 System Safety FAA definition the application of special technical and managerial skills in a systematic, forward-looking manner to identify and control hazards throughout the life cycle of a project, program, or activity Flight Instructor Training Module. Volume 2: System Safety Course Developers Guide. Flight Standards Service, General Aviation and Commercial Division, AFS training/fits/training/flight instructor/media/volume2.pdf. Accessed July 2, 2010

62 Safety Culture

63 Crew Resource Management Definition (Lauber) - Use all available resources Information Equipment People Achieve safe and efficient operations Lauber JK. Cockpit resource management: background and overview. In: Orlady HW, Foushee HC, eds. Cockpit Resource Management Training. Moffett Field, Calif.: National Aeronautics and Space Administration Scientific and Technical Information Branch; NASA conference publication 2455.

64 CRM Break the chain of poor decisions Root cause starts well before procedure

65 Original CRM Studies 1979 Ruffell Smith The results showed that the number of errors was very variable among crews but the mean increased in the higher workload case

66 Original CRM Studies 1984 Billings & Reynard Human Error causes or contributes to over half of all aviation mishaps

67 Original CRM Studies 1991 Diehl Training in Decision Making Reduced Error 8%-46% CRM Strategies Reduced Accident Rates 36%-81%

68 CRM Related Medical Literature 1994 Leape

69 CRM Related Medical Literature 1999

70 CRM Related Medical Literature 2000 Sexton, et al Error is difficult to discuss in medicine and not all staff accept personal susceptibility to error

71 CRM Related Medical Literature 2003 Gawande, et al Surgeons acknowledged more than 1/3 of their cases resulted from error

72 CRM Related Medical Literature 2010 Semel, et al

73 CRM Related Medical Literature 2011 Haynes, et al BMJ Qual Saf :

74 What is a CRM Checklist? Informational tool used to reduce failure Compensates for limits of Memory Attention Insures consistency and completeness of a task

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76 Play Video One How Not to Run a Checklist

77 Play Video Two How to Run a Checklist Properly

78 Aug 2010

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80 Appointment Review

81 Before Procedure

82 Procedure

83 Before Dismissal

84 After Dismissal

85 Benefit of CRM Checklists Standardization Protocol identical Independent of: Procedure Operator Patient

86 Benefit of CRM Checklists Easy to do the right thing, difficult to do the wrong thing Ensures skills are performed in a repeatable and reliable manner no matter who is on the team Overcome human limitations - prevent, trap and mitigate error Focus on patient care rather than mundane or repeatable tasks

87 Benefit of CRM Checklists Create Time in High Workload Environments Shift Duties to Low Workload Periods Passivity and Repetition Can Mask Complexity

88 Noise Mitigation

89 Aug 2010 Journal of the American Dental Association

90 JADA Letter from Editor July 7, 2010 Harold M. Pinsky, DDS Re: JADA author JADA proof for review articles typically go through Dear Dr. Pinsky: Attached is a PDF of the typeset galley of the article, Adaptation of Airline..., which has been prepared for the August 2010 issue of JADA. We are introducing this stage of author review to provide additional quality control. We ask that you return any corrections you may have no later than three Friday, July 9th, so that readings we can meet our printer s deadline. by the editorial staff Please notify me that you have received this material by ing me at sniderj@ada.org calling me at 800/ , ext Then print out the proof and review it carefully for errors of fact. While you read it, the editorial staff is reviewing it for style, grammar, layout and consistency, once so please confine they your review to have issues of clinical and been scientific accuracy typeset, and other facts (such as author so information) that can best be confirmed by you. Please mark any essential changes clearly in ink and fax them to me at Note: We cannot accept changes made in Adobe Writer. JADA articles please typically go through do three readings not by the editorial be staff too once they have concerned been typeset, so please do not be by too concerned by any typographic or layout errors you find. Be assured that we are finding them as well. Please note that this material is copyrighted by the American Dental Association and therefore may not be distributed in any way or form. If the author s institution wishes to publicize the publication of the article, please have the appropriate person contact the American Dental Association s any Media Relations typographic Department (phone , or mediarelations@ada.org ). layout errors All publicity about material published in JADA must be coordinated with the ADA s media relations staff. To ensure that the article is included in the August 2010 issue, I ask that I have your comments and corrections no later than 2:00 p.m. CST on Friday, July you 9th. If have find. no corrections Be to make, assured please notify me of that well. that If I do not hear we from you are by this deadline, I will assume that you have no changes to report. Thank you very much. I look forward to hearing from you. Sincerely, Janice Snider Senior Editor 312/ sniderj@ada.org Attachments finding them as well. VIA

91 JADA Initial Publication

92 JADA Initial On Line Human Error is Inevitable cv

93 JADA Initial Pub Med cv

94 JADA Google

95 Human Error is Inevitable Mulhouse-Habsheim Airport, France

96 Thank You