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Cross-Industry Application of Cross-Industry Application of an Aviation Model for an Aviation Model for Confidential ReportingConfidential Reporting
2005 Michigan Health & Safety Coalition Patient Safety Conference
Dearborn, MI
April 7, 2005
Linda Connell, Director,Linda Connell, Director,NASA Aviation Safety Reporting SystemNASA Aviation Safety Reporting System
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Ames Research Center
Dryden Flight Research Center
Langley Research Center
Glenn Research Center
Jet Propulsion Laboratory
Johnson Space Center
Marshall Space Flight Center
Goddard Space Flight Center
Kennedy Space Center
NASA CentersNASA Centers
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NASA Ames Research CenterNASA Ames Research Center
30-year history of Aviation Human Factors Research
•Human Error, Decision-making, Fatigue, CRM
NASA Center of Excellence in Information Technology
•Data mining and visualization tools•High reliability computing•Human-Computer Interaction
Proven track record as independent, competent and trustworthy manager of safety data:
Aviation Safety Reporting System (ASRS)•29 years of experience - 640,000 reports •NEVER a single breach of confidence
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HUMAN PERFORMANCE CONTRIBUTION TO
ERROR
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Aviation Safety Aviation Safety Reporting System Reporting System
(ASRS)(ASRS)
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Aviation Tragedy Leads to Aviation Tragedy Leads to Genesis of ASRSGenesis of ASRS
TWA 514, December 1, 1974TWA 514, December 1, 1974
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Overview SummaryOverview Summary
• ASRS established in 1976 as an independent, confidential, voluntary reporting system for aviation at NASA with FAA offering “immunity” to reporters.One of the first lines of defense in identifying safety issuesNASA chosen as “Honest Broker”Located at NASA Ames Research Center due to Aviation
Human Factors expertise and research—it was recognized that approximately 70% of all accidents are human factors related.
• ASRS database is a national asset of U.S. aviation
safety data
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Guiding PrinciplesGuiding Principles
VOLUNTARY PARTICIPATIONAviation personnel voluntarily submit reports concerning events
related to safety for the purpose of system alerting, understanding and learning
CONFIDENTIALITY PROTECTIONProtection of identity is provided by NASA through de-
identification of persons, companies, and any other information
NON-PUNITIVEFAA will not use, nor will NASA provide, any report submitted for
inclusion under ASRS guidelines or information derived therein for use in any disciplinary or other adverse action.
(Advisory Circular 0046D)
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StakeholdersStakeholders
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Normal Operations
Incidents
InjuryAccidents
Fatal Accidents
ASRS is Complementary to Other Systems of Reporting
Event OccurrencesEvent Occurrences
{FAA & NTSB
{ASRS
Precursors
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ASRS PURPOSEASRS PURPOSE
Identify Deficiencies and Discrepancies
Provide Data for Planning
and Improvements
ALERTS PRODUCTS
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ASRS Expert Analyst StaffASRS Expert Analyst Staff
• Aviation Operational Expert Analysts perform initial screening, identification of alerts, initial analyses, database coding, and special studies (e.g., structured callback interviews and consultation on special safety topics).
• Expert Analysts are retired air carrier pilots (Part 121 and 135), retired air traffic controllers, retired maintenance technicians, general aviation pilots, and flight attendants. A minimum of 10 years aviation experience required.
• Years of aviation experience of the current analyst staff totals to approx. 390 yrs. An average of 35.5 yrs experience in aviation.
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Annual ASRS Report Intake
ASRS Report ASRS Report IntakeIntake
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
'81 '82 '83 '84 '85 '86 '87 '88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02
Smoothed / Forecast
Actual Intake• An Increase of 70%
Since 1988
• Averaging 2,900 Reports Per Month
• 145 per working day
• Total 2003 Report Intake = 34,043 Reports
• Intake projected to exceed 34,000 in 2004
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INCIDENT REPORTER DISTRIBUTIONINCIDENT REPORTER DISTRIBUTION
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ProductsProducts
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ASRS Genesis of Human FactorsResearch at NASA Ames
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ASRS Database
Alert Messages
Research
FAA & NTSB Quick Responses
Monthly Safety Newsletter Quarterly Safety Bulletin
Incident Reports
Database Search Requests
CD ROM
ASRS PRODUCTS & SERVICESASRS PRODUCTS & SERVICES FOR THE AVIATION COMMUNITY FOR THE AVIATION COMMUNITY
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PUBLICATIONSPUBLICATIONS
• CALLBACK is ASRS's award-winning monthly safety bulletin that began publication in 1979. It has an estimated readership of more than 150,000. Over 260 issues have been published and distributed throughout the U.S. and to the international aviation community. All issues are available for download at the ASRS website.
DIRECTLINE Is another award-winning ASRS publication. This safety journal has an estimated distribution / readership of 20,000. Ten issues have been published since 1991 with a baseline of three to five articles per issue. All issues are available for download at the ASRS website.
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ASRS Home Page http://asrs.arc.nasa.gov
ASRS Database Access at FAA NASDAC Site:http://nasdac.faa.gov
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International Confidential Aviation International Confidential Aviation Safety SystemsSafety Systems
ICASSICASS
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ASRS - Model for Other ASRS - Model for Other Operational SystemsOperational Systems
There has been growing interest from a variety of disciplines desiring the
safety benefits realized in aviation.
Numerous organizations have requested
assistance from the ASRS in creating reporting
systems designed to help them understand and learn about their own
systems.
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CROSS-INDUSTRY APPLICATIONCROSS-INDUSTRY APPLICATION
NASA and Department of NASA and Department of Veterans AffairsVeterans Affairs
Patient Safety Reporting SystemPatient Safety Reporting System(PSRS)(PSRS)
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The VA’s Efforts TowardsThe VA’s Efforts TowardsPatient Safety ImprovementsPatient Safety Improvements
Vision for Change Initiated
NationalPatient SafetyPartnership19
97
1998
1999
VA National Center forPatient SafetyEstablished (NCPS)
2000
The VA Patient Safety Changes Were Initiated in 1995
The PSRS is an Expansion of the VA’s Commitment to Quality and Safety
DevelopmentOf NASA/VAPatient SafetyReporting System(PSRS)
Patient SafetyCenters ofInquiryEstablished
1995
Expert AdvisoryPanel Meetings
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INSTITUTE INSTITUTE OF OF MEDICINE MEDICINE REPORTREPORT
Released Released 19991999
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Medical Performance FactorsMedical Performance Factors
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VA and NASA Launch VA and NASA Launch Agreement for PSRSAgreement for PSRS
• May ‘00 - Interagency Agreement signed between NASA and Department of Veterans Affairs– Dr. Thomas Garthwaite, Under Secretary of Health
– Dr. Henry McDonald, Director, NASA Ames Research Center
• NASA Ames Research Center, Moffett Field, CA and VA National Center for Patient Safety, Ann Arbor, MI are collaborating to maximize patient safety efforts– Dr. Jim Bagian, Director of NCPS– Ms. Linda Connell, Director of PSRS
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Event Chain
Operational System
Human Performance
SystemImprovement &
Learning
Incidents &Close Call
Events
Sentinel Events
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VA Staff Invited to ParticipateVA Staff Invited to Participate
Any VA staff or personnel working in
VA facilities are invited to submit voluntary reports concerning
medical safety
• Physicians• Nurses• Laboratory• Radiology• Pharmacy• Rehabilitation• Dietitians• Support Staff• Others
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PSRS Reports – Reporter Types*
* Other Staff
* Unknown
Respiratory Therapist
Physician Assistant
Nurse Anesthetist
Lab Technician / Assistant
Medical Technologist
Rehabilitation Specialist
Nurse Practioner
Environmental / Engineering Services
Licensed Practical / Vocational Nurse
Pharmacist
Nursing Assistant
Physician
Registered Nurse
0% 5% 10% 15% 20% 25% 30% 35% 40% 45%
13.08%
18.53%
0.27%
0.54%
0.54%
0.82%
1.09%
1.63%
1.63%
1.91%
1.91%
2.72%
4.90%
6.81%
43.60%
*As of March 2004
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PSRS Reports – Anomaly TypesPSRS Reports – Anomaly Types**
*As of March 2004
Other
Order-Related
Monitoring
Building Design / Structure
Patient Transport
Medication / Other
Treatment / Technique
Medication
Staffing
Maint. Engin. Housekeeping
Non-Adherance to Policy/Procedure
Medical Equipment Problem
Delay in Treatment / Diagnosis
Medication Dispensing Anomaly
Documentation / Communication
0% 5% 10% 15% 20% 25% 30% 35%
23%
5%
5%
5%
8%
8%
8%
9%
9%
10%
13%
13%
15%
17%
33%
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Feedback toFeedback toVA Reporting CommunityVA Reporting Community
• 5 Patient Safety Bulletins (PSBs) have been issued since April 2003
• 10 Issues of FEEDBACK – PSRS Quarterly
Newsletter – distributed
since August 2002
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Linking Risk Assessment Linking Risk Assessment with Risk Managementwith Risk Management
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• Encompasses:Risk Assessment
Risk Mitigation
Evaluation of Residual Risk
Risk Acceptance
Risk ManagementRisk Management
Confidential Reporting Model Has Confidential Reporting Model Has Specific Contributions to:Specific Contributions to:
Risk AssessmentRisk Assessment
NASA NPG 2810.1
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Nine Steps of Risk AssessmentNine Steps of Risk Assessment
1) System Characteristics
2) Threat Identification
3) Vulnerability Identification
4) Control Analysis
5) Probability Determination
6) Impact Analysis
7) Risk Determination
8) Control Recommendations
9) Results Documentation
NASA NPG 2810.1
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Human Factors, Risk Identification, Safety Assessment, Insights
Alerting Messages, Special Studies
Charles E. Billings, MD. (1998). “The NASA Aviation Safety Reporting System: Lessons Learned from Voluntary Incident Reporting.” In Proceedings of National Patient Safety Foundation Conference, Enhancing Patient Safety and Reducing Errors in Health Care, Chicago (pp. 97-100).
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SUMMARY
WHY CONFIDENTIAL REPORTING WORKS
• When organizations want to learn more about the occurrence of events, the best approach is simply to ask those involved.
• People are generally willing to share their knowledge if they are assured:
• Their identities will remain protected
• There is no disciplinary or legal consequences
• A properly constructed confidential, voluntary, non-punitive reporting system can be used by any person to safely share information
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WHY CONFIDENTIAL REPORTING WORKS
• Confidential reporting systems have the means to answer the question why - why a system failed, why a human erred
• Incident/event data is complementary to the data gathered by other monitoring systems
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Confidential Reporting Can - Confidential Reporting Can - Provide the “Big Picture”Provide the “Big Picture”
• Most other data sources lack the ability to capture the information that this type of reporting receives.- Reporting from a broad population of system users- Reporting covers the full spectrum of safety concerns
• Reporting system can target specific populations for special study and expanded information gathering- Structured Callback Studies- Routine telephone callback- Special Studies
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Thank you for Thank you for your interest and your interest and
attentionattention