title: NASA Model of "Threat and Error" in Pediatric Cardiac Surgery: Patterns of Error Chains.
abstract: BACKGROUND
  We introduced the National Aeronautics and Space Association threat-and-error model to our surgical unit. All admissions are considered flights, which should pass through stepwise deescalations in risk during surgical recovery. We hypothesized that errors significantly influence risk deescalation and contribute to poor outcomes.
  
  
  METHODS
  Patient flights (524) were tracked in real time for threats, errors, and unintended states by full-time performance personnel. Expected risk deescalation was wean from mechanical support, sternal closure, extubation, intensive care unit (ICU) discharge, and discharge home. Data were accrued from clinical charts, bedside data, reporting mechanisms, and staff interviews. Infographics of flights were openly discussed weekly for consensus.
  
  
  RESULTS
  In 12% (64 of 524) of flights, the child failed to deescalate sequentially through expected risk levels; unintended increments instead occurred. Failed deescalations were highly associated with errors (426; 257 flights; p < 0.0001). Consequential errors (263; 173 flights) were associated with a 29% rate of failed deescalation versus 4% in flights with no consequential error (p < 0.0001). The most dangerous errors were apical errors typically (84%) occurring in the operating room, which caused chains of propagating unintended states (n = 110): these had a 43% (47 of 110) rate of failed deescalation (versus 4%; p < 0.0001). Chains of unintended state were often (46%) amplified by additional (up to 7) errors in the ICU that would worsen clinical deviation. Overall, failed deescalations in risk were extremely closely linked to brain injury (n = 13; p < 0.0001) or death (n = 7; p < 0.0001).
  
  
  CONCLUSIONS
  Deaths and brain injury after pediatric cardiac surgery almost always occur from propagating error chains that originate in the operating room and are often amplified by additional ICU errors.
authors.affiliation: Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada. Electronic address: edward.hickey@sickkids.ca.
authors.forename: Edward
authors.initials: E
authors.lastname: Hickey
authors.affiliation: Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.
authors.forename: Eric
authors.initials: E
authors.lastname: Pham-Hung
authors.affiliation: Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.
authors.forename: Yaroslavna
authors.initials: Y
authors.lastname: Nosikova
authors.affiliation: Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.
authors.forename: Fredrik
authors.initials: F
authors.lastname: Halvorsen
authors.affiliation: Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Gritti
authors.affiliation: Division of Cardiac Critical Care, The Hospital for Sick Children, Toronto, Ontario, Canada.
authors.forename: Steven
authors.initials: S
authors.lastname: Schwartz
authors.affiliation: Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Caldarone
authors.affiliation: Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.
authors.forename: Glen
authors.initials: G
authors.lastname: Van Arsdell
mesh_terms: D000367:Age Factors; D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000706:statistics & numerical data*; D002648:Child; D006801:Humans; D019300:Medical Errors / Q000009:adverse effects* / Q000706:statistics & numerical data*; D015233:Models, Statistical; D017064:Process Assessment, Health Care; D018570:Risk Assessment; D012307:Risk Factors; D014481:United States; D018557:United States National Aeronautics and Space Administration