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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

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.

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)

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

INSTITUTE INSTITUTE OF OF MEDICINE MEDICINE REPORTREPORT

Released Released 19991999

Medical Performance FactorsMedical Performance Factors

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

Event Chain

Operational System

Human Performance

SystemImprovement &

Learning

Incidents &Close Call

Events

Sentinel Events

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

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

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%

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

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