Matthew J. W. Thomas

Fatigue-proofing: A new approach to reducing fatigue-related risk using the principles of error management

In this review we introduce the idea of a novel group of strategies for further reducing fatigue-related risk in the workplace. In contrast to the risk-reduction achieved by reducing the likelihood an individual will be working while fatigued (e.g., by restricting hours of work), fatigue-proofing strategies are adaptive and protective risk-reduction behaviours that improve the resilience of a system of work. That is, they increase the likelihood that a fatigue-related error will be detected and not translate into accident or injury, thus reducing vulnerability to fatigue-related error. The first part of the review outlines the theoretical underpinnings of this approach and gives a series of ethnographically derived examples of informal fatigue-proofing strategies used in a variety of industries. A preliminary conceptual and methodological framework for the systematic identification, development and evaluation of fatigue-proofing strategies is then presented for integration into the wider organisational safety system. The review clearly identifies fatigue-proofing as a potentially valuable strategy to significantly lower fatigue-related risk independent of changes to working hours. This is of particular relevance to organisations where fatigue is difficult to manage using reductions in working hours due to operational circumstances, or the paradoxical consequences for overall safety associated with reduced working hours.

The Breakdown of Coordinated Decision Making in Distributed Systems

Objective: This article aims to explore the nature and resolution of breakdowns in coordinated decision making in distributed safety-critical systems. Background: In safety-critical domains, people with different roles and responsibilities often must work together to make coordinated decisions while geographically distributed. Although there is likely to be a large degree of overlap in the shared mental models of these people on the basis of procedures and experience, subtle differences may exist. Method: Study 1 involves using Aviation Safety Reporting System reports to explore the ways in which coordinated decision making breaks down between pilots and air traffic controllers and the way in which the breakdowns are resolved. Study 2 replicates and extends those findings with the use of transcripts from the Apollo 13 National Aeronautics and Space Administration space mission. Results: Across both studies, breakdowns were caused in part by different types of lower-level breakdowns (or disconnects), which are labeled as operational, informational, or evaluative. Evaluative disconnects were found to be significantly harder to resolve than other types of disconnects. Conclusion: Considering breakdowns according to the type of disconnect involved appears to capture useful information that should assist accident and incident investigators. The current trend in aviation of shifting responsibilities and providing increasingly more information to pilots may have a hidden cost of increasing evaluative disconnects. Application: The proposed taxonomy facilitates the investigation of breakdowns in coordinated decision making and draws attention to the importance of considering subtle differences between participants’ mental models when considering complex distributed systems.

Failures in transition: learning from incidents relating to clinical handover in acute care.

&NA; The appropriate handover of patients, whereby responsibility and accountability of care is transferred between healthcare providers, is a critical component of quality healthcare delivery. This paper examines data from recent incidents relating to clinical handover in acute care settings, in order to provide a basis for the design and implementation of preventive and corrective strategies. A sample of incidents (n = 459) relating to clinical handover was extracted from an Australian health services incident reporting system using a manual search function. Incident narratives were subjected to classification according to the system safety and quality concepts of failure type, error type, and failure detection mechanism. The most prevalent failure types associated with clinical handover were those relating to the transfer of patients without adequate handover 28.8% (n = 132), omissions of critical information about the patients condition 19.2% (n = 88), and omissions of critical information about the patients care plan during the handover process 14.2% (n = 65). The most prevalent failure detection mechanisms were those of expectation mismatch 35.7% (n = 174), clinical mismatch 26.9% (n = 127), and mismatch with other documentation 24.0% (n = 117). The findings suggest the need for a structured approach to handover with a recording of standardized sets of information to ensure that critical components are not omitted. Limitations of existing reporting processes are also highlighted.

Where Failures Occur in the Imaging Care Cycle: Lessons From the Radiology Events Register

Adverse events contribute to significant patient morbidity and mortality on a global scale, and this has been documented in a number of international studies. Despite this, there is limited understanding of medical imagings involvement in such events. Incident reporting is a key feature of high-reliability organizations because, understandably, it is essential to know where things go wrong and why as the very first step in formulating preventative and corrective strategies. Although anesthesiology has led the way, health care in general has been slow to adopt this technique, and this includes medical imaging. Knowledge as to where medical imaging incidents are initiated and detected, and why, is not well documented or appreciated, although this is critical information in relation to quality improvement. Using an online radiology reporting system, the authors therefore sought to gain further insight and also ascertain where failures are located in the imaging cycle, and whether different incidents sources provide different information. Last, the authors sought to examine the resilience of the imaging system using these incident data.

Restricted sleep and negative affective states in commercial pilots during short haul operations

This study aims to investigate (1) the relationship between restricted sleep and Heightened Emotional Activity (HEA) during normal flight operations, and (2) whether sleep patterns influence the strength of the HEA as a response to threats. Accident investigation reports continue to highlight the relationship between restricted sleep and poor safety outcomes. However, to date we have a limited understanding of how sleep and HEA interact. A total of 302 sectors of normal airline flight operations were observed by trained observers, and instances of heightened emotional activity were recorded. During the cruise phase of each of these sectors, crew members were asked to calculate the amount of sleep they had obtained in previous 24 and 48 h. In the 302 sectors of normal flight operations, 535 instances of HEA were observed. Descriptive analyses of instances of HEA and sleep in the prior 24 and 48 h showed a significant relationship between the occurrence of HEA and recent sleep. The relationship between restricted sleep and HEA suggests that there may well be further implications with respect to operational safety.

WORK HOURS AND SLEEP/WAKE BEHAVIOR OF AUSTRALIAN HOSPITAL DOCTORS

The objective of the study was to describe the work and sleep patterns of doctors working in Australian hospitals. Specifically, the aim was to examine the influence of work-related factors, such as hospital type, seniority, and specialty on work hours and their impact on sleep. A total of 635 work periods from 78 doctors were analyzed together with associated sleep history. Work and sleep diary information was validated against an objective measure of sleep/wake activity to provide the first comprehensive database linking work and sleep for individual hospital doctors in Australia. Doctors in large and small facilities had fewer days without work than those doctors working in medium-sized facilities. There were no significant differences in the total hours worked across these three categories of seniority; however, mid-career and senior doctors worked more overnight and weekend on-call periods than junior doctors. With respect to sleep, although higher work hours were related to less sleep, short sleeps (< 5 h in the 24 h prior to starting work) were observed at all levels of prior work history (including no work). In this population of Australian hospital doctors, total hours worked do impact sleep, but the pattern of work, together with other nonwork factors are also important mediators. (Author correspondence: sally.ferguson@unisa.edu.au)

Fatigue risk management by volunteer fire-fighters: Use of informal strategies to augment formal policy

An increasing number and intensity of catastrophic fire events in Australia has led to increasing demands on a mainly volunteer fire-fighting workforce. Despite the increasing likelihood of fatigue in the emergency services environment, there is not yet a systematic, unified approach to fatigue management in fire agencies across Australia. Accordingly, the aim of this study was to identify informal strategies used in volunteer fire-fighting and examine how these strategies are transmitted across the workforce. Thirty experienced Australian volunteer fire-fighters were interviewed in August 2010. The study identified informal fatigue-management behaviours at the individual, team and brigade level that have evolved in fire-fighting environments and are regularly implemented. However, their purpose was not explicitly recognized as such. This apparent paradox - that fatigue proofing behaviours exist but that they are not openly understood as such - may well resolve a potential conflict between a culture of indefatigability in the emergency services sector and the frequent need to operate safely while fatigued. However, formal controls require fire-fighters and their organisations to acknowledge and accept their vulnerability. This suggests two important areas in which to improve formal fatigue risk management in the emergency services sector: (1) identifying and formalising tacit or informal fatigue coping strategies as legitimate elements of the fatigue risk management system; and (2) developing culturally appropriate techniques for systematically communicating fatigue levels to self and others.

Non-technical skills of surgical trainees and experienced surgeons

In addition to technical expertise, surgical competence requires effective non‐technical skills to ensure patient safety and maintenance of standards. Recently the Royal Australasian College of Surgeons implemented a new Surgical Education and Training (SET) curriculum that incorporated non‐technical skills considered essential for a competent surgeon. This study sought to compare the non‐technical skills of experienced surgeons who completed their training before the introduction of SET with the non‐technical skills of more recent trainees.

Effect of working consecutive night shifts on sleep time, prior wakefulness, perceived levels of fatigue and performance on a psychometric test in emergency registrars

Objective: To evaluate the effect of working consecutive night shifts on sleep time, prior wakefulness, perceived levels of fatigue and psychomotor performance in a group of Australian emergency registrars.

Flight Hours and Flight Crew Performance in Commercial Aviation

OBJECTIVE To examine the relationship between a pilots flight hours and their performance. BACKGROUND There is current debate in the aviation industry on the minimum hours required for first officers to gain before they can fly for an airline. Despite years of pilot training and licensing, there are very little data available to determine whether or not pilot performance varies as a function of total hours within an airline environment. METHOD Flight crew performance was measured during 287 sectors of normal operations against a set of technical and nontechnical measurements. Flightcrew were grouped into a categorical variable which defined low and high experience groups according to industry accepted thresholds. RESULTS There were no statistically significant differences between experience groups for First Officers or Captains against the set of technical measures; however, there were minor differences with regard to nontechnical measures as a function of crew composition. There was also a difference in automation use, with First Officers with less than 1500 h keeping the autopilot engaged until a significantly lower altitude. DISCUSSION Despite on-going debate that low-hour First Officers are not as capable as their more experienced colleagues, we found no evidence of this in our study.