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Volume1 Issue4
I
ssues and
P
eople
Several airlinecrashes in the1970s
wereattributed tocommunication
failures, inadequate teamworkbycrew
members, interruptionsof established
protocols andhierarchical airline
culture. Detailedanalysesof these
crashesdemonstratedachainofminor
individualmistakes that collectively
led tocatastrophicevents.
12
While
communication failureshavebeen
citedas contributing factors in43%
of adverseoutcomes after surgery,
13
surgeons rarely investigate their failures
since failures impact onlyoneperson
at a time.
14
This lackof investigation
of failuresmayhave slowed the
development of approaches for
improvingpatient safety.
Thecausesof airlinecrashes and
errors ingeneral areconsistentwith
Reason’smodel of accident trajectory,
15
which suggests that defences are
not foolproof (
Fig. 1
). In thismodel,
defences are likened toparallel arraysof
rotating slicesof Swiss cheese: theholes
in the slices representweaknesses in
individual partsof thedefence system.
Whenacritical number of holes (i.e., risk
factors) align, a trajectory for accident
opportunity is created. Subsequently, a
hazardmaypass through thedefensive
holes and lead toanerror andpossibly,
anaccident.
Crew resource
management and the
dental office
In response to the largenumber of
airlinecrashes in the1970s thatwere
attributed tohuman factors, Crew
ResourceManagement (CRM)was
developed inconjunctionwithNASA
and theNational TransportationSafety
Board.
16,17
CRM is typicallydefined
as anapproach that uses available
information, equipment andpersonnel
to realize safeandefficient flight
operations. CRMencompasses team
trainingaswell as simulation, interactive
groupbriefings,measurement and
improvement of crewperformance. At
thefirst level, CRMadvocates for error
avoidance. At the second level, potential
errors are identifiedby the teambefore
theyarecommitted. At the third level,
mitigationof theconsequencesof error
occurs.
CRM involves implementingcultural
changewithin theworkplace. Success
or failure isportrayedas a team, rather
thanan individual, issue.While there is
no single, standardized team training
program for healthcare, all programs
should stress several keyapproaches. In
thedental office, team training should
minimize thepotential for error by
implementingpre-treatment briefings.
Dentistsneed tominimizehierarchy
in their operatoriesbycreatingan
atmosphere inwhichall personnel feel
comfortable speakingupwhen they
suspect aproblem. A teammember
may see something thedentist is
oblivious to, suchasundetectedcaries
or a tooth that is about to receive
inappropriate treatment. Dental team
members shouldbeencouraged to
cross-checkeachother’s actions, offer
assistancewhenneeded, andaddress
errors inanon-judgmental fashion.
Thecreationof backup systems, cross-
checkingandconfirmationareessential
componentsof aneffective team
strategy toenhancepatient safety in
thedental office (
Table1
).
Incontrast tomedical care, dental
services aregenerallydelivered in small,
independent clinics. Unlikea surgeon
inahospital operating room, dentists
define their ownhoursof operation
andworkwith the same staffmembers
ona routinebasis. Indeed, the relative
constancyof dental office staffcan
facilitate team trainingandobviate
oversights in treatment. Oversights are
associatedwithhuman factors that
includecomplacency, fatigue, poor
communication, and lackof aproper
descriptionof possiblecomplications.
These factors couldbeaddressedby
implementationof CRMprotocols, as
illustratedby the followingexample.
Acomparativeanalysisof dutyhours
showed that airlinecrews aremuch
more likely to recognize fatigueas a risk
factor thanare surgeons.
18
Candentistry
be that different?We suggest that since
humanerror is inevitable,management
techniques areneeded tohelp identify
and traperror before it develops into
unexpected, adverseoutcomes. One
approach is theapplicationof risk
analysis,which increases situational
awarenessof potential error and
emphasizes earlyerror detection.
19
Hazard
Harm
Hazard
ErrorTrajectoryStopped
Discs represent successive layersof
defences andbarriers toaccidents
Holes indiscs represent
weakness indefences
Figure1:
Conceptual diagram illustrating concepts developedbyReason
15
of accident
trajectory. In thismodel, defences arenot foolproof andare similar to the illustratedar-
rays of parallel discs.Whena critical number of holes are aligned, a trajectory foraccident
opportunity is createdandahazardmaypass through thedefensiveholes, thereby leading
toanaccident.Theholes representweakness indefences.LatentFailures include organ-
izational influences, poor trainingandpre-conditions suchas fatigue.ActiveFailures
includeunsafe actions.
