Skip to main content Accessibility help
×
Home

Implementation of a “threat and error” model in complex neonatal cardiac surgery patients to identify quality improvement opportunities

  • Deanna R. Todd Tzanetos (a1), Vicki Montgomery (a1), William Harrington (a2) and Aaron Calhoun (a1)

Abstract

Introduction:

Neonates undergoing surgery for congenital heart disease are vulnerable to adverse events. Conventional quality improvement processes centring on mortality and significant morbidity leave a gap in the identification of systematic processes that, though not directly linked to an error, may still contribute to adverse outcomes. Implementation of a multidisciplinary “flight path” process for surgical patients may be used to identify modifiable threats and errors and generate action items, which may lead to quality improvement.

Methods:

A retrospective review of our neonatal “flight path” initiative was performed. Within 72 hours of a cardiac surgery, a meeting of the multidisciplinary patient care team occurs. A “flight path” is generated, graphically illustrating the patient’s hospital course. Threats, errors, or unintended consequences are identified. Action items are generated, and a working group is formed to address the items. A patient’s flight path is updated weekly until discharge. The errors and action items are logged into a database, which is analysed quarterly to identify trends.

Results:

Thirty one patients underwent flight path review over a 1-year period; 22.5% (N = 7) of patients had an error-free “flight.” Eleven action items were generated – four from identified errors and seven from identified threats. Nine action items were completed.

Conclusions:

Flight path reviews of congenital cardiac patients can be generated with few resources and aid in the detection of quality improvement opportunities. The regular multidisciplinary meetings that occur as a part of the flight path review process can promote inter-professional teamwork.

Copyright

Corresponding author

Author for correspondence: Deanna Todd Tzanetos, MD, MSCI, 571 S. Floyd St. Suite 332 Louisville, KY40202, USA. Tel: +1 502 852 8633; Fax: +1 502 852 3998; E-mail: drtzan01@louisville.edu

References

Hide All
1.Catchpole, KR, Giddings, AEB, Wilkinson, M, et al. Improving patient safety by identifying latent failures in successful operations. Surgery 2007; 142: 102110.
2.Catchpole, KR, Giddings, AEB, De Leval, MR, et al. Identification of systems failures in successful paediatric cardiac surgery. Ergonomics 2006; 49: 567588.
3.Barach, P, Johnson, JK, Ahmad, A, et al. A prospective observational study of human factors, adverse events, and patient outcomes in surgery for pediatric cardiac disease. J Thorac Cardiovasc Surg 2008; 136: 14221428.
4.Carthey, J, de Leval, MR, Reason, JT.The human factor in cardiac surgery: errors and near misses in a high-technology medical domain. Ann Thorac Surg 2001; 72: 300305.
5.Jacques, F, Anand, V, Hickey, E, et al. Medical errors: the performance gap in hypoplastic left heart syndrome and physiologic equivalents. J Thorac Cardiovasc Surg 2013; 145: 14651475.
6.Thiagarajan, R, Bird, G, Harrington, K, et al. Improving safety for children with cardiac disease. Cardiol Young 2007; 17: 127132.
7.Bowermaster, R, Miller, M, Ashcraft, T, et al. Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room. J Am Coll Surg 2015; 220: 149155.
8.De Leval, MR, Carthey, J, Wright, DJ, et al. Human factors and cardiac surgery: a multicenter study. J Thorac Cardiovasc Surg 2000; 119: 661672.
9.Wilson, T, Holt, T.Complexity and clinical care. BMJ 2001; 323: 685688.
10.Hickey, EJ, Nosikova, Y, Pham-Hung, E, et al. National Aeronautics and Space Administration “threat and error” model applied to pediatric cardiac surgery: error cycles precede ~85% of patient deaths. J Thorac Cardiovasc Surg 2015; 149: 496507.
11.Elhoff, JJ, Lasa, JL.What’s the flight plan, Captain? Ped Crit Care Med 2017; 18: 598599.
12.Reason, J.Human Error. Cambridge University Press, Cambridge, 1990.
13.Spear, SJ.Fixing healthcare from the inside: teaching residents to heal broken delivery processes as they heal sick patients. Acad Med 2006; 81: S144S149.
14.Reason, J.Human error: models and management. BMJ 2000; 320: 768770.
15.Spear, SJ.Fixing healthcare from the inside, today. Harv Bus Rev 2005; 83: 7891.
16.Beauchamp, MR, McEwan, D, Waldhauser, KJ.Team building: conceptual, methodological, and applied considerations. Curr Opin Psychol 2017; 16: 114117.

Keywords

Implementation of a “threat and error” model in complex neonatal cardiac surgery patients to identify quality improvement opportunities

  • Deanna R. Todd Tzanetos (a1), Vicki Montgomery (a1), William Harrington (a2) and Aaron Calhoun (a1)

Metrics

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed.