What's Wrong with Your Cath Lab and Mine: Lessons from Aviation Zoltan G. Turi, M.D. Rutgers Robert Wood Johnson Medical School New Brunswick, NJ
No relevant conflicts
In the world of aviation, there is no tolerance for error. The reasons are obvious. Applying principles learned by the aviation community to increase safety in the medical environment has a long way to go.
When There is Zero Tolerance Checklists Training Preflight inspection In-Flight Sterile cockpit Cockpit resource management Two pilot operation Communications Order read backs Report and analyze if it goes bad
Checklists
Checklists Summer night in Detroit August 16, 1987 Needed to get to Orange County by way of Phoenix; running behind Skipped one checklist item Forgot to put down flaps Need more lift: Hot/humid day High altitude Tailwind/little headwind Short runway
Almost All Aircraft Accidents are Multifactorial Central Aural Warning System (CAWS) in place 28 V device controls CAWS Tended to go off during taxi many crews intentionally disabled it
This Aircraft Accident Was Multifactorial Too Forgot to put down flaps CAWS never signaled alarm Hot, humid night Little wind Runway length?
X X X 10,000 8,500 10,000
A Little Forgetfulness Dead - 154 Survived one little girl
Implementation of a Surgical Safety Checklist Dutch study of ~ 4,000 patients Complications 39% Surgical mortality 47% from 1.5 % to 0.8% de Vries EN et al. N Engl J Med 2010;363:1928-1937
Cath Lab Do We Need Checklists? Allergies, HIT, renal function To give anticoagulation To check ACTs regularly To keep track of contrast use To keep track of fluoro time To remember to give antibiotics And it is easy to completely forget about ancillary planned procedures or to do the wrong one
Checklists
Coming Soon to Everywhere We Do Procedures And It s About Time!!
US Air 1549
The greatest factor contributing to the success of Flight 1549 was the use of a checklist But there was another important lesson from Flight 1549:
Training Equipment - Aviation Time in simulator Written test Proficiency with all controls Fund of knowledge Minimum passing grade If you fail, you don t fly Regularly repeated Not just for pilots crew as well Lives are at stake Anything less is unacceptable
Training Equipment - Hospitals No simulator No test for physician or staff of Proficiency with controls Fund of knowledge In fact the only requirement for me to use this complex multimillion dollar equipment: Lives are at stake This should be unacceptable
Indian Air Acquires A320 Airbus February 1990 First full glass cockpit and all digital fly -by-wire Indian Air had previously acquired A300 Airbus Paid foreign pilots to fly with Indian pilots Elected to save money and use simulators only for A320 training
Follow-up visit Take a fellow, tech, statistician Fly Detroit-NRTBKK-BOM-HYD Happened to be in February 1990
Along the Way
Night takeoff from Bombay 1st week Indian Air had A 320 in operation On climb out, grinding noises My fellow was oblivious to grinding noises and swatted flies the entire time Circled field Landed Got towed to terminal
Next Afternoon A320 enroute from BOM to Bangalore Descended in clear air to runway Mistakenly set autopilot for rate of descent instead of approach mode Discovered that they were headed short of runway Attempted to command go -around
Go around = command wings level Climb to preset altitude Altitude not set factory setting = 0
Training - Procedures
Document Experience
Document training and experience
Physician/PA/nurse/tech training Maintenance of minimum competency Overall Individual procedures Do not assign 10 different nurses to help with your lab s 12 carotid stents per year Do not assign 5 different MDs to do your 12 carotid stents per year And finally Do not do carotid stenting if the institution only does 12 per year!
How Do You Become and Stay Competent
OK we re trained, we ve got out cheklists, let s go flying
Preflight All equipment available? Equipment working?
Preflight inspection Walkaround physical exam, time outs
In-flight
Eastern Flight 212 September 11, 1974 Charleston to Chicago, stop in Charlotte On descent into Charlotte Discussed Watergate Looked for amusement park
Captain: "Right. I heard this morning on the news while I was... might stop proceedings against impeachment [of the president]" [sound of altitude warning beep] 1000 ft Captain: "...because you can't have a pardon for Nixon and the Watergate people. Old Ford's beginning to take some hard knocks..." First Officer: "We should be taking some definite direction to save the country. Arabs are taking over every damned thing." First Officer: "...The stock market and the damned Swiss are going to sink our damned money, gold over there..." Captain: "Yes sir boy. They got the money, don't they? They got so much damned money." First Officer: "...Yeah, I think, damn if we don't do something by 1980, they'll [presumably "the Arabs"] own the world." Captain: I'd be willing to go back to one... to one car... a lot of other restrictions if we can get something going." 11:33:44 CHARLOTTE TOWER:Eastern 212, clear to land, three six. 11:33:52 CAPTAIN to Copilot:Yeah, we're all ready. All we got to do is find the airport.
One half second later they both shouted and the DC-9 crashed They were 3 miles short of the runway 10 of 82 on board survived
Sterile Cockpit FAR 135.100 Below 10,000 feet No flight crewmember may engage in, nor may any pilot in command permit: Activities such as eating meals, engaging in nonessential conversations within the cockpit and nonessential communications between the cabin and cockpit crews.
Meanwhile Back in the Control Room
During Procedures Sterile cockpit during important portions Quarantine from intrusions: No cell phones, beepers, telephones Quarantine from distractions No web surfing, etc. No conversations extraneous to the work at hand No food
Cockpit Resource Management Bombay 747 takeoff dark night 329 souls on board Pilot instruments failed Copilot and flight engineer recognize problem but do not speak up forcefully Pilot flies airplane into ocean Palace in the Sky
Team Communication 14 month old child with congenital heart disease and CHF Order given for 0.7 mg of IV digoxin Correct dose = 0.07 mg Nurse recognizes the error, afraid to speak up Child has 55 minute cardiac arrest Pronounced dead
1 vs 2 pilot operations accident rate > 20x with single pilot operations Air Force Lessons for hospital 2 attendings for high risk procedures 2 attendings for live demonstration courses Pilot in command is clearly identified
Readbacks
N28JW = november-two-eight-juliet-whiskey
N28JW Heading to LAS 9,000 feet on frequency 125.7 mhz X RHYME
If There Were No Readbacks ATC: November two-eight-juliet-whiskey cross RHYME at 8 contact Las Vegas approach on 124.75 N28JW misunderstands descends to 7,000 feet and switches over to 122.75 ATC unable to contact airplane when N28JW passes below 8,000
PSA 182 Sept 25, 1978 San Diego Cessna on training flight Told to fly 070 degrees Flies at 090 degrees PSA 727 on approach PSA Cessna
30 seconds later
Death toll 144 + 7
If There are Readbacks ATC: November two-eight-julietwhiskey cross RHYME at 8 contact Las Vegas approach on 124.75 Me: November two-eight-juliet-whiskey is cleared to RHYME, out of 9 for 8, over to 124.75 ATC: November two-eight-julietwhiskey good day sir. Me: Two-eight-juliet-whiskey good day
In the Cath Lab Closed Loop Communications MD - Please give 4,000 of heparin If no readback? given? dose given? drug given RN Heparin 4,000 got the order RN - Heparin 4,000 is in given the drug Monitor Heparin 4,000 got it logged properly
My Experiences 1. Heparin dose acknowledged but never given a. coronary artery thrombosed b. large heart attack 2. Ordered Vitamin V a. didn t appear to work b. given Vitamin K c. nothing happened
What if You Screw Up? Voluntary no-fault reporting QI with independent evaluation and recommendations Root cause analyses Comparison to benchmarked database All of these applicable to hospital and office practices
There is no tolerance for error in aviation There should be no tolerance for error anywhere in medicine
Keep the Shiny Side Up