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They Lost Situational Awareness - that's a kind way to say "asleep at the wheel"

October 23, 2009
by Joe Bormel
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In today's WSJ, there's

an article "Wandering Flight Spurs Nap Probe" that describes Northwest Flight 188:


They took off from San Diego and had been flying at an altitude of 37,000 feet when contact was lost, eventually circled back and landed safely in Minneapolis without injuries. For a normal approach, the plane should have started slowing and descending as much as 30 minutes prior to touchdown.




The article caught my attention for multiple reasons. Last week, I flew on similar route, from San Diego on a major airline, under the impression that airline safety, as well as Airbus A320 design, made this kind of thing pretty much impossible. Apparently, from this same article, this same week a Delta Boeing 767 landed on something other than the intended runway. Isn't GPS sensitive to a few feet? The GPS in my car tells me exactly which lane I'm in on a 4-lane highway. Hardware and software cost? Under $100. Technology is supposed to help make us safer.




Another dimension was pilot fatigue. Early the same day, I was reading a series of articles discussing physician fatigue, distraction, and even a

JAMA study (see links there) on improving physician "mindfulness" against extreme multitasking-induced fatigue.






Blackberry, iPhone, and other distractions from "Being Here Now" Developing greater mindfulness—a quality of being fullypresent and attentive in the moment—has been proposedas an approach for addressing the psychological distress (burnout)reported by some physicians.




But I think the largest dimension that triggered this blog post was the "lost situational awareness" idea. I have been a long advocate to use HIT to improve situational awareness. In my

recent TORCH presentation, I included a screenshot of a flowsheet definition to assure that no item of a pre-operative checklist is overlooked. (It's slide 21

here.) The IHI calls this approach to not leaving anything out as "Bundles." And yet, as I review the readily available systems, both vendor and home grown, there's still an extremely strong bias toward

only providing "Departmental Views" of data. That means, a tab for laboratory, a tab for X-rays, a tab for orders, a tab for notes, etc. Sure, you can add a flowsheet definition or report after go live. What's involved in making that happen? Almost always the total cost prohibits it from happening. The cost includes people coordinating behaviors, processes being understood, skills being present and available. And, of course, the IT tools supporting customization that is often deemed "optional."




I appreciate that we need to replicate the paper chart for a variety of reasons. We're still a far cry from ideal electronic processes. That can only start with leadership to create the kind of processes that help keep pilots, physicians, nurses, and HIT executives reliably on course. Even without enough sleep!




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Comments

Joe,
Did you notice the plug for napping?

"Though the practice of nodding off midflight in the cockpit is prohibited by the FAA, U.S. airlines and pilot unions say there is a growing body of research supporting the notion that so-called controlled napping by part of a cockpit crew can enhance safety by making crews more alert during critical, often hectic descents and landings."

From: http://www.kk.org/outofcontrol/ch16-g.html

The Airbus A320 is capable of landing the plane without pilot intervention:

"The pilots joked that the computer was like putting a dog into the cockpit. The dog's job was to bite the pilot if he tries to touch the controls and the pilot's only job was to feed the dog"

The reference above provides some great insights they clearly apply to HCIT decision support:

"The original idea was that human pilots would monitor the computer in case anything went wrong. The only problem is that humans are terrible at passive monitoring. They get bored. They daydream. Then they start missing critical details. Then an emergency pops up which they have to tackle cold."

Joe Bormel

Healthcare IT Consutant

Joe Bormel

@jbormel

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