safety compass newsletter 12-2013

8/12/2019 Safety Compass Newsletter 12-2013

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HAVE iPhone - WILL TRAVELBy David Carr Director of Safety

DECEMBER 2013

HAVE iPhoneWILLTRAVEL

Steep & Slow; WiresBelow

lying Aviation SafetyConcepts To Reduce

Patient Error

Safety Donts

2013 Incident Stats

Beware, Tunnel Vision AheadI was in a rush to get to the airport for another Med-Transadventure. I loaded up my stuff in the back, and being in afrenzied state of mind, opted out of opening the car door formy wife (Error #1 of many).

I slid behind the wheel, fired up the family truckster andbacked out of the garage. Full steam ahead. Destination:

the always-glamorous DFW airport. About 10 miles into ourjourney, going from 0-70-back to crawl, walk and run speeds,we had cleared most of the traffic and realizing that I had afree moment to multi-task, reached for my cell phone tocheck which terminal I would be flying out of.

My hand searched at first then grappled and grasped,reaching for the cellphone that is ALWAYS where I put it, inthe center console cup holdernothing but air.

1Pilots, being right brained are prone to setting up systems.Procedures we mentally and physically put in place to

ensure we dont miss anything. When you have 3 radiosgoing off, an LZ improperly setup, and two medicalprofessionals prepping for the worst case scenario patientpickup , the mission can get distracting and complicated in a

really big hurry. Cue our fallbacksystems. We reach for thechecklist to run through the do-or-hurt yourself items; you instinctivelyknow where all the buttons are youhave memorized your cockpit soyoud be ready for such things; youmentally go through a task list tomake sure all the bases are

covered, then you follow wellpracticed procedures of reconningthe LZ, cause you know that when itcomes to a safe outcome, firstresponders are involved, but you arecommitted. These are pieces of yoursurvival strategy. After all, you onlyhave:

My search was in vain. I looked down and my greatestfear was realized. No phone, where a phone wassupposed to be! I dont I dont know about you, but jusbut just about everything of value (with the exception of myfamily) is in some fashion in that phone. Precious photos,contact list of hundreds and important notes, not to mentionit was set up exactly how I wanted it ( who wants to go

through setting up a phone more than once a decade ?).My mind shifted to troubleshooting. Did my wife have it inher purse. No. Is it in my back pocket, No. Is it still pluggedin at home. Maybe, or did I put it on the back bumper as Iwas loading my stuff?

Is That Steve Jobs Spinning In His Grave?Stage II panic. As I looked for an opening in traffic to getoff the highway, Stage II panic escalated to stage III when Idared to consider the possibly that I had made theunpardonable sin. I found a spot with a wide shoulder, Ieased off the gas and brought the 6000 lb. SUV to a

standstill. Even in my panicked state of mind, I glancedout the side view mirror for traffic before opening thedoor another piece of my survival strategy. As Iproceeded to the back bumper, my minds eye wasconjuring images of little bits of Steve Jobs wonderphonescattered about Hwy 121. As I made the turn, I lookeddown and there it was, my prized iPhone 4 restingcomfortably on the back bumper, just where I left it.


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Misery Loves Company Shown below is empirical evidence that when it comes toeaving stuff on my vehicle, Im in good company:

The same can be said in our flight operations. Med-Trans isveraging one incident a month of something left on, out thathould be in, connected to that shouldnt be, or hanging out

of our aircraft.

An unsecure door opens in flight. Probably not the end of theworld, unless a bed sheet goes with it. You can ask our AirEvac brethren about that one. How about stuff left on theamp that a patient might need in flight. The oops gets moreerious. What about stuff left on that falls off in flight? I

wouldnt want to be under our aircraft as a radio plummetsike a homesick brick from 500 feet above (1lb @ terminal

velocity = new Med-Trans patient + lawsuit).

Why does it continue to happen? We are all trained, we are

ll professional, we all care. Here are my thoughts: Muchike my adventure to the airport, we get busy, in a rush, were

kicking up dust to get stuff loaded and on our way--hey, wehave lives to save people! Somewhere along the wayhough, we miss the part about backing each other up. Oneast check to make sure weand our stuff are together,ecure and ready to gallop off.

POLICY BETA TESTING UPDATE

If you recall from last months Safety Compass newsletter, we explained a new approach to developing and fielding newpolicies or major changes to current policies. First, the proposed policy was published for a two week comment period, thenthe changes were reviewed. Ten of 13 recommendations were made and the revised draft policy was beta tested by twoB407 and two EC135 bases for two weeks.

The next step in the policy evolution is to review the feedback from those bases, make final changes and publish the policy.The feedback comments are posted on the Sharepoint Safety Page as is the proposed policy. It will be updated periodicallyuntil it becomes a real live policy. https://sharepoint.med-trans.net/Safety/default.aspx

Thanks to all who took the time to provide comments, recommendations and feedback. Your opinions are appreciated.

DECEMBER 201
https://sharepoint.med-trans.net/Safety/default.aspxhttps://sharepoint.med-trans.net/Safety/default.aspxhttps://sharepoint.med-trans.net/Safety/default.aspxhttps://sharepoint.med-trans.net/Safety/default.aspx


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APPLYING AVIATION SAFETY CONCEPTS TO REDUCEPATIENT SAFETY ERRORS Part I

DECEMBER 20

By Connie Eastlee

VP, Program Operations

In the 2000 Institute of Medicines (IOM) report To Err isHuman, it was estimated that health care errors in theUnited States contribute annually to between 48,000 and96,000 in-patient deaths.

Why Hospitals Should Fly is an excellent book that compares the similarities betweenaviation and healthcare. The author madethe following analogy. Medical mistakeslikely occur to 22-30 patients every hour ofevery day amounting to a staggering totalof 100,000-250,000 unnecessary patientinjuries every year-- the equivalent of crashing ten fullyloaded Boeing 747s every week.

Air Medical Transport is a high-risk environment for healthcare error due to the presence of critical and complicatedpatient physiology, the high volume of tasks, extensivemultitasking and predictable gaps in the continuity of care intransporting the patient from one place to another. (scene tohospital etc.).

When you compare aviation safety and patient safetyliterature the terminology may be slightly different but theconcepts are the same. Error exists when a plannedsequence of activities, either mental or physical, does notachieve the intended outcome. Either the plan did notproceed as intended or the plan itself was inadequate. Anerror is a mistake, inadvertent occurrence or unintendedevent in an aviation or health care delivery [that] may or maynot result in injury.

From an article in a 2012 edition of Critical Care Nurse titledStrategies for Improving Patient Safety: Linking Task Typeto Error Type . Three types of errors are described in detail.

1. Skill-Based Errors which include Slips and Lapses. Slipsand lapses occur during automatic or skill -based tasks:

A slip is an observable, external failure in the physicalexecution of ones plan. Slips generally result from deficitsin attention or perception. The failure to focus onesattention at a critical moment during an automatic (routine)task creates an opportunity for error. Slips and lapses mayalso occur from over attention during a routine task. When attention is placed on the wrong thing, the result is skippingor repeating steps in the task/checklist, or even in a reversalof the task/checklist.

Sound familiar? How many times have you given amedication or performed a walk-around, your attentionis diverted and the dosage is different than youintended, or a clipboard was left on the helicopter skid?

2. Lapses are internal, less visible to an outside observer.Lapses occur from failure of memory storage and manifestin many different ways. Lapses commonly contribute toerrors of omission, which can have serious consequences.

An example of a lapse called reduced intentionality wouldbe when you start walking towards the room where therefrigerated medications or Blood product is to pick upbefore a flight and enroute something distracts you and youcant remember what you were headed in that direction forand continue on to get in the aircraft without the medicationsor blood (and you thought this was just a result of old age).

3. Mistakes occur when the actions proceed as planned, butthe plan itself is inadequate to achieve its intended aim.Essentially, the strategy used to solve the problem is flawed.There are two distinct types of mistakes: rule based andknowledge based.

Rule-Based Mistakes: Selecting the wrong path involvesthe acknowledgment of a problem to be addressed anda departure from skill-based, reflective performance.

Knowledge-Based Mistakes occur when we areconfronted with novel events where skill-based and rule-based behavior are deemed inapplicable. Thesesituations require deliberate and conscious problem

solving. How often do we arrive at a Critical AccessHospital which rarely sees a pediatric sepsis patient?The hospital staff must rely on knowledge basedbehavior as skills and rule based behavior will not help.

Ultimately, most tasks are governed by skill-based or rule-based behavior, and thus most errors occur during theseprocesses. Hence the use of initial and recurrenttraining for skills and checklists, policies andprocedures for rules (sounds like Aviation).

But if a task is not skill-based or rule-based and falls toknowledge-based behavior, the rate of error relative toopportunity increases significantly.

So how do we decrease our Human Errors? Safety(whether patient or aviation) requires error and riskmanagement which refers to both error reduction (limitthe occurrence of the error/frequency of the risk) anderror containment (measures designed to enhancedetection and recovery of an error/probability of theseverity of the risk).

At Med-Trans we utilize the Risk Management Matrix foridentifying Hazards (prior to the error). We have been usinga risk assessment and its associated risk managementmatrix for many years. In the near future though, expect to

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DECEMBER 20

Sitting in the doctors office waiting room provided me with some time to kill. I looked around and saw everyone else gluedto their smartphone. So I took the road less traveled. I was sifting through ancient editions of various magazines when Ihappened upon a dogeared issue of Glamour. Instantly, I recollected my favorite part, the section in the back titledFashion Dos and Donts . While perusing the various pictures I stumbled on a fun idea. Why not add a lightheartedsection entitled Safety Donts at the end of each newsletter. A nd so, an idea was born. If you would like to contribute,send me your Darwin-Award worthy pics and I will include them in future editions.

Here are my top shots for December. Bask in the glory of our fellow human beings putting their critical decision makingskills on display.

see risk assessments for our aircraft maintenance andclinical operations. Both are a necessary additions to ourSafety Management System because the risks we face

include risks faced in all of our day to day operations, not just flying. Part Two - next month on how to Reduceand Contain Errors.

LEARN FROM THE EXPERIENCE OF OTHERSIT HURTS LESS


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If you have a safety concern, or if something in your operation doesnt seem right, you have tools available. First, speak up! Get your supervisor involved. Submit a hazard report/Safety Concern. If you are uncomfortable with

either of those options, you can submit your concerning via our compliance hotline anonymously at:

800 399 2319.

The Med-Trans Safety Compass monthly newsletteris one method we have of communicating with everyemployee. We want this newsletter to be a forum forfostering a culture of informing and learning.

I welcome your suggestions on topics you would liketo see addressed here. Better yet, send me yourarticle and I will get it added in the next issue.

Feel free to contact me by phone or email, my virtualdoor is always open.

David CarrDirector of Safety

Director of SafetyDavid [email protected]

The Med Trans Leadership Team

Chief Operating OfficerRob [email protected]

Director of OperationsBert [email protected]

VP, Program OperationsConnie [email protected]

Director of MaintenanceJosh [email protected]

Chief PilotDon [email protected]

Assistant Chief PilotMike [email protected]

VP, Flight OperationsBrian [email protected]

DECEMBER 20
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safety compass newsletter 12-2013

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