On error management: Lessons from aviation

Abstract

In aviation,accidents usually highly visible,and as a result aviation has developed standardised methods of investigating, documenting, and disseminating errors and their lessons. Although operating theatres are not cockpits, medicine could learn from aviation. Observation of flights in operation has identified failures of compliance, communication, procedures, proficiency, and decision making in contributing to errors. Surveys in operating theatres have confirmed that pilots and doctors have common interpersonal problem areas and similarities in professional culture. Accepting the inevitability of error and the importance of reliable data on error and its management will allow systematic efforts to reduce the frequency and severity of adverse events.