Professional Aviation Research Articles

Learning from aviation safety: a call for formal "readbacks" in surgery

The first fatal airplane crash in history occurred exactly 100 years ago, on September 17, 1908, when Army lieutenant Thomas Selfridge died in a failed flight attempt with the aviation pioneer Orville Wright. Since that time, aviation safety standards have significantly improved. Currently, the risk for an American dying in an airplane crash is about 1:500,000, compared to a 1:20,000 chance of dying in a car accident. In the field of medicine, it was not until the shocking report by the Institute of Medicine in 1999 revealed that 100,000's of patients die in the United States every year as a consequence of medical errors [1], when we began to realize that there is something with the system. While this unacceptably high number has been chronically underrated in public recognition, an extrapolation of these statistics to professional aviation equals to about 200 jumbo jet crashes per year, or one 747 crash every other day. This dramatic insight led to the design of the 100,000 lives by the Institute for Healthcare Improvement in 2004 [2]. By 2006, the campaign had surpassed its initial goal by saving more than 120,000 lives through the implementation of increased patient safety standards and algorithms [2]. These include the recent implementation of a standardized surgical time-out to ensure the correct patient identity and correct procedure performed at the correct surgical site [3]. In addition, the implementation of formal, structured perioperative briefings in the operating room have been shown to significantly reduce the incidence of wrong site surgeries [4]. Despite those recent improvements, the analysis of the American College of Surgeons' closed claims study revealed that a breakdown in communication before, during, or after surgery still represents a significant source of errors which lead to patient complications [5]. Of these, 85% of adverse events related to communication breakdown occurred by verbal communication, while only 4% were attributed to communication in written form [5]. This notion provides the basis for a call for written checklists and formal verbal orders among healthcare professionals who care for surgical patients, in order to avoid or reduce the high incidence of perioperative complications related to a breakdown in communication. Interestingly, pilot represent a hallmark safety concept in professional aviation. While the current debate in aviation safety is related to optimizing and correcting the modality of [6,7], this crucial form of communication is still virtually nonexistent among surgeons. Dr. Eddie Hoover has characterized the issue to the point, in a recent editorial: Getting surgeons to readback orders and instructions will age you 10 years, yet the Navies of the world have demonstrated for eons that it improves efficiency, promotes safety, and saves lives. [8]. I wish to emphasize that the implementation of verbal readback orders represents the 2nd National Patient Safety Goal (NPSG) for 2009, as defined by the Joint Commission [9]. The NPSG #02.01.01, aimed at improving the effectiveness of communication among caregivers, is defined as such: For verbal or telephone orders or for telephone reporting of critical test results, the individual giving the order or test result verifies the complete order or test result by having the person receiving the information record and 'read back' the complete order or test result. [9]. In conclusion, I urge all healthcare professionals involved in the care of surgical patients to contribute to improved patient safety and reduced complications and sentinel events in 2009 by addressing the most frequent root cause for adverse outcome in surgery: Ineffective communication. The implementation of formal standardized readbacks is a promising start.

The Influence of a Perceptual-Motor Training Activity on the Stability of PC-Based Cognitive Test Scores: A Repeated Measures Paradigm

The authors repeatedly administered four computerized tests to 21 students engaged in a lengthy PC-based flight training simulation as part of their pre-training activities at a professional aviation academy. Test scores were examined for disruption, or evidence of transfer, during intervals in which the tests were expected to correlate with training performance. No significant disruptions were noted for grammatical reasoning, code substitution, or four-choice reaction time. However, the BFITS group experienced significant improvement on one test (air defense maneuvering) during the predicted interval. The effect was not mirrored by either of two control groups (flight instructors and university undergraduates). Implications for performance prediction are discussed.

Aviation Curriculum Design

Historically, aviation education has been in the hands of the pilot poorly qualified as an educator. With the explosion of knowledge in the past quarter century, it is imperative that aviation education be addressed by professional aviation educators.

Bilingual Air Traffic Control in Canada

Simulation exercises with bilingual controllers from Montreal Center were conducted in order to develop procedures for the safe implementation of bilingual communications for aircraft operating under instrument flight rules in the Province of Quebec. Representative pilots from professional and general aviation associations flew aircraft simulators linked to the Air Traffic Control simulator in order to evaluate the proposed bilingual system and to generate data on the party-line aspect of the listening watch in air-ground communications. The effects of language, type of sector, traffic characteristics, and exceptional conditions on communication characteristics and controller performance were observed in four different studies. In addition, data on controllers' communications in actual operations and on reported incidents involving the listening watch were obtained. Information from both the simulations and the real-world operations were then analyzed to determine the implications for control procedures and to assess the general impact of bilingual control on system safety.

ATC Simulations for the Implementation of Bilingual IFR Control in Canada

Enroute and Terminal Control Area simulation exercises involving certified bilingual controllers from Montreal Center have been conducted in order to develop procedures for the implementation of bilingual IFR control in the Province of Quebec. The enroute phase of the program was designed to determine the effect of bilingual control on controller performance and the supplementary procedures required in both a radar and non-radar environment. The effects of traffic load, language, and type of sector on communication characteristics, controller errors, and control effectiveness were also observed. In the terminal control phase, the effect of varying work load as a function of the runway-in-use was also included in the analysis of arrival and departure control. Aircraft simulators integrated within the simulations, initially by voice-link and later by data-link, enabled representative pilots from professional aviation associations to evaluate the simulation exercises and the proposed bilingual system. Independent exercises investigated bilingual control procedures in situations of an exceptional nature in the terminal and enroute sectors.

ASYMPTOMATIC DISEASE OF CORONARY ARTERIES IN YOUNG MEN.

Epidemiol?gica! and pathological studies of atherosclerosis have recently received impetus through the agency of the World Health Organization. This work, together with the majority of the previous literature, is largely concerned with overt disease and death from coronary heart disease ; there is a comparative dearth of information on the preva lence of occult affection of the coronary arteries, the study of which cannot be divorced from that of ischaemic heart disease (Strong and McGill, 1962). So as to eliminate any possible adverse effects of unrelated disease on the health of the coronary arteries, the basic extent of symptomless atheroma must be sought in supposedly healthy persons killed accidentally rather than in hospital populations ; most of the relevant reports have therefore emanated from military medicine. M?nckeberg (1915a, 1915b, 1916) appears to have been the first to explore this field. His three series include 167 combatant troops compared with 136 men exempt from war service, all of whom were killed either in action or accidentally ; atherosclerosis was discovered in 50.9% of the combatants and in 63.2% of the non-combatants, the potentiating effect of age being demonstrated in both groups?even so, 44.5% of soldiers under the age of 30 were found to be affected to some extent. This study must surely have been followed up, but the next apposite refer ence that 1 discovered is that Enos, Holmes, and Beyer (1953). These authors made a strictly comparable study of American soldiers killed in action in Korea. Narrowing of one or more coronary arteries resulting in more than 50% restriction was found in 12.3% of 300 cases, the average age of the men being 22.1 years. In civilian life, Spain and Bradess (1959) reported their findings in 166 white men aged 31-60 who were killed accidentally ; they confirmed the presence of widespread asymptomatic coron ary atheroma, although completely normal arteries were discovered even in a proportion of their oldest subjects. Strong and McGill (1962) also studied accidental death and concluded that it was impossible to divide American white males into those having and not having coronary athero sclerosis after the age of 20 years?the only distinction lay in the severity of disease. The activities of the Joint Committee on Aviation Pathology (Brody, 1957) have in recent years focused attention on the occurrence of pre-existing disease in air crew?possibly the most highly physically selected group available?who ' were killed while flying, and numerous articles have been published from the United States of America dealing in general terms with coronary arterial disease in the context of aircraft accident pathology (Town send, 1957; Berry and Stembridge, 1958; Silliphant and Stembridge, 1958; Townsend and Stembridge, 1958; Townsend and Davidson, 1961). Specific studies of occult coronary arterial disease in American aircrew have been reported from the Armed Forces Institute of Pathology (Glantz and Stembridge, 1959 ; Townsend and Glantz, 1959; Rigal, Lovell, and Townsend, 1960; Catherman, Davidson, and Townsend, 1962). Depending primarily on the age-group involved and secondarily on the method of examination, these various authors have assessed the incidence of restrictive disease as from 14% in the age group 20-24 to 32% marked sclerosis?that is, more than 75% restriction?in the age-group 40-49 years. Compar able British series of aircrew fatalities have been reported (Mason, 1959, 1962 ; Stevens, 1961, 1962), but the articles have been of a limited distribution. It is also noted that the problem has been considered by the Soviet Air Force (Koldovski, Novak, and Vorel, 1961); this article has been seen only in abstract form. It therefore seemed appropriate to collect and publish the British data in more readily available form so that valid comparisons of the occurrence of asymptomatic coronary arterial disease in physically fit young men on both sides of the Atlantic could be made. The significance in aviation of discovered arterial disease could be threefold. Firstly, it might be shown to be a disease state directly related to the stresses of professional aviation. Secondly, it might be shown to be a significant cause of unexplained aircraft accidents ; this possibility is not considered in detail in this paper. Thirdly, it could be no more than a marker of the incidence of atherosclerosis throughout the population.