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Related Experiment Video

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Instrumentation of Near-term Fetal Sheep for Multivariate Chronic Non-anesthetized Recordings

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Aviation-Modeled Investigation of Significant Obstetric Events.

Nicole Powell-Dunford^1,2, Patricia Deuster¹, Mark McPherson³

¹Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda MD 20814.

Military Medicine

|March 17, 2020

Summary

The Root Cause Analysis Event Support and Engagement Team (RESET) inconsistently investigates aviation techniques in serious obstetrical events. Standardizing investigations and training can improve medical error analysis using aviation safety principles.

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Area of Science:

Medical error investigation
Aviation safety principles
Obstetrics and Gynecology

Background:

Root Cause Analysis (RCA) is a method to find the underlying cause of problems, originating in manufacturing and engineering.
RCA is increasingly applied to medical error investigations.
The Root Cause Analysis Event Support and Engagement Team (RESET) investigates significant medical errors in U.S. Army facilities.

Purpose of the Study:

To determine if RESET investigates aviation-based techniques in serious obstetrical events.
To assess the consistency of RESET investigations regarding aviation safety practices in obstetrics.

Main Methods:

A structured, anonymous, voluntary survey was administered to RESET staff.
The survey assessed the investigation of specific aviation-based techniques during RCA of obstetrical events.

Main Results:

Five of six RESET members completed the survey.
Prebriefs, debriefs, and checklist use were consistently investigated.
Sterile cockpit, first-name introductions, annual check rides, and emergency procedure rehearsals were infrequently investigated.

Conclusions:

RESET investigations do not consistently examine all aviation-based techniques in serious obstetrical events.
Standardizing investigative procedures and educating staff on under-investigated practices can enhance medical investigations.
Adopting aviation-based approaches can optimize the analysis of medical errors in obstetrics.