National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac surgery: error cycles precede ∼85% of patient deaths.
BACKGROUND
We hypothesized that the National Aeronautics and Space Administration "threat and error" model (which is derived from analyzing >30,000 commercial flights, and explains >90% of crashes) is directly applicable to pediatric cardiac surgery.


METHODS
We implemented a unit-wide performance initiative, whereby every surgical admission constitutes a "flight" and is tracked in real time, with the aim of identifying errors. The first 500 consecutive patients (524 flights) were analyzed, with an emphasis on the relationship between error cycles and permanent harmful outcomes.


RESULTS
Among 524 patient flights (risk adjustment for congenital heart surgery category: 1-6; median: 2) 68 (13%) involved residual hemodynamic lesions, 13 (2.5%) permanent end-organ injuries, and 7 deaths (1.3%). Preoperatively, 763 threats were identified in 379 (72%) flights. Only 51% of patient flights (267) were error free. In the remaining 257 flights, 430 errors occurred, most commonly related to proficiency (280; 65%) or judgment (69, 16%). In most flights with errors (173 of 257; 67%), an unintended clinical state resulted, ie, the error was consequential. In 60% of consequential errors (n = 110; 21% of total), subsequent cycles of additional error/unintended states occurred. Cycles, particularly those containing multiple errors, were very significantly associated with permanent harmful end-states, including residual hemodynamic lesions (P < .0001), end-organ injury (P < .0001), and death (P < .0001). Deaths were almost always preceded by cycles (6 of 7; P < .0001).


CONCLUSIONS
Human error, if not mitigated, often leads to cycles of error and unintended patient states, which are dangerous and precede the majority of harmful outcomes. Efforts to manage threats and error cycles (through crew resource management techniques) are likely to yield large increases in patient safety.
Divisions of Cardiovascular Surgery and Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Canada. Electronic address: edward.hickey@sickkids.ca.
Edward J
EJ
Hickey
Divisions of Cardiovascular Surgery and Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Canada.
Yaroslavna
Y
Nosikova
Divisions of Cardiovascular Surgery and Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Canada.
Eric
E
Pham-Hung
Divisions of Cardiovascular Surgery and Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Canada.
Michael
M
Gritti
Divisions of Cardiovascular Surgery and Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Canada.
Steven
S
Schwartz
Divisions of Cardiovascular Surgery and Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Canada.
Christopher A
CA
Caldarone
Divisions of Cardiovascular Surgery and Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Canada.
Andrew
A
Redington
Divisions of Cardiovascular Surgery and Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Canada.
Glen S
GS
Van Arsdell
D006348:Cardiac Surgical Procedures / Q000401:mortality; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control* / Q000706:statistics & numerical data*; D010372:Pediatrics; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D014481:United States; D018557:United States National Aeronautics and Space Administration
aviation; error; resource management; threat