Improving healthcare communication: Lessons from the flightdeck

Improving Healthcare Team Communication: Building on Lessons from Aviation and Aerospace

Volumn , Issue , 2008, Pages 23-45

  Orasanu, Judith ^a   Fischer, Ute ^b  

^a NASA AMES RESEARCH CENTER   (United States)

^b Institute of Technology   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

EID: 77956799262     PISSN: None     EISSN: None     Source Type: Book    
DOI: None     Document Type: Chapter

References (81)

1. Austin, J.L. (1962), How to Do Things with Words (London: Oxford University Press).
2. Baker, D.P., Beaubien, J.M. and Holtzman, A.K. (2006), DoD Medical Team Training Programs: An Independent Case Study Analysis (prepared by the American Institutes for Research under Contract No. 282-98-0029, Task Order No. 54 No. AHRQ Publication No. 06-0001) (Rockville, MD: Agency for Healthcare Research and Quality).
3. Bales, R.F. (1976), Interaction Process Analysis: A Method for the Study of Small Groups (Chicago, IL: The University of Chicago Press).
4. Billings, C.E. and Cheaney, E.S. (1981), Information Transfer Problems in the Aviation System, NASA Tech. Paper 1875 (Moffett Field, CA: NASA Ames Research Center).
5. Bogner, M.S. (ed.) (1994), Human Error in Medicine (Mahwah, NJ: Erlbaum).
6. Brown, P. and Levinson, S.C. (1987), Politeness: Some Universals in Language Usage (Cambridge: Cambridge University Press).
7. Chidester, T.R., Kanki, B.G., Foushee, H.C., Dickinson, C.L. and Bowles, S.V. (1990), Personality Factors in Flight Operations: Volume 1. Leader Characteristics and Crew Performance in a Full-Mission Air Transport Simulation (No. NASA Tech. Mem. 102259) (Moffett Field, CA: NASA Ames Research Center).
8. Coiera, E., Jayasuriya, R., Hardy, J., Bannan, A. and Thorpe, M. (2002), 'Communication Loads on Clinical Staff in the Emergency Department', Medical Journal of Australia 176:9, 415-18.
9. Coiera, E. and Tombs, V. (1998), 'Communication Behaviours in a Hospital Setting: An Observational Study', British Medical Journal 316:7132, 673-6.
10. Cooper, G.E., White, M.D. and Lauber, J.K. (eds) (1980), Resource Management on the Flightdeck: Proceedings of a NASA/Industry Workshop (NASA CP-2120) (Moffett Field, CA: NASA Ames Research Center).
11. Cushing, S. (1997), Fatal Words: Communication Clashes and Aircraft Crashes (Chicago, IL: The University of Chicago Press).
12. Donchin, Y., Gopher, D., Olin, M., Badihi, Y., Biesky, M., Sprung, C.L., Pizov, R.P. and Cotev, S. (1995), 'A Look into the Nature and Causes of Human Errors in the Intensive Care Unit', Critical Care Medicine 23:2, 294-300.
13. Dyer, J.L. (1984), 'Team Research and Team Training: A State of the Art Review', in F. Muckler (ed.), Human Factors Review (Santa Monica, CA: Human Factors Society).
14. Endsley, M.R. (1995), 'Toward a Theory of Situation Awareness', Human Factors 37:1, 32-64.
15. Endsley, M.R. (2000), 'Theoretical Underpinnings of Situation Awareness: A Critical Review', in M.R. Endsley and D.J. Garland (eds), Situation Awareness Analysis and Measurement (Mahwah, NJ: Erlbaum) 3-32.
16. Fischer, U. (1999). Cultural Variability in Crew Discourse, Final Report on NASA Cooperative Agreement NCC 2-933 (Atlanta, GA: Georgia Institute of Technology).
17. Fischer, U. and Orasanu, J. (1999), 'Say it Again, Sam! Effective Communication Strategies to Mitigate Pilot Error', in R.S. Jensen (ed.), Proceedings of the 10th International Symposium on Aviation Psychology (Columbus: Ohio State University) 362-6.
18. Fischer, U. and Orasanu, J. (2000), 'Error-challenging Strategies: Their Role in Preventing and Correcting Errors', Proceedings of the International Ergonomics Association 14th Triennial Congress and the 41st Meeting of the Human Factors and Ergonomics Society (San Diego, CA: HFES) 30-33.
19. Fischer, U., Rinehart, M. and Orasanu, J. (2001), 'Training Flight Crews in Effective Error Challenging Strategies', paper presented at the Eleventh International Symposium on Aviation Psychology, Columbus, OH.
20. Fletcher, G., McGeorge, P., Flin, R., Glavin, R.J. and Maran, N.J. (2002), 'The Role of Non-technical Skills in Anaesthesia: A Review of Current Literature', British Journal of Anaesthesia 88:3, 418-29.
21. Flin, R., Fletcher, G., McGeorge, P., Sutherland, A. and Patey, R. (2003), 'Anaesthetists' Attitudes to Teamwork and Safety', Anaesthesia 58:3, 233-42.
22. Foushee, H.C. (1982), 'The Role of Communications, Socio-psychological and Personality Factors in the Maintenance of Crew Coordination', Aviation, Space and Environmental Medicine 53, 1062-6.
23. Foushee, H.C. (1984), 'Dyads and Triads at 35,000 Feet: Factors Affecting Group Process and Aircrew Performance', American Psychologist 39:8, 885-93.
24. Foushee, H.C., Lauber, J.K., Baetge, M.M. and Acomb, D.B. (1986), Crew Factors in Flight Operations: III. The Operational Significance of Exposure to Shorthaul Air Transport Operations (NASA Technical Memorandum 88322) (Moffett Field, CA: NASA Ames Research Center).
25. Foushee, H.C. and Manos, K.L. (1981), 'Information Transfer within the Cockpit: Problems in Intracockpit Communications', in C.E. Billings and E.S. Cheaney (eds), Information Transfer Problems in the Aviation System, NASA Report No. TP-1875. (NTIS No. N81-31162) (Moffett Field, CA: NASA Ames Research Center) 63-71.
26. Gaba, D.M. and Howard, S.K. (2002), 'Patient Safety: Fatigue Among Clinicians and the Safety of Patients', New England Journal of Medicine 347:16, 1249-55.
27. Ginnett, R.C. (1987), 'The Formation Process of Airline Flight Crews', in R.S. Jensen (ed.), Proceedings of the 4th International Symposium on Aviation Psychology (Columbus, OH: Ohio State University) 399-405.
28. Ginnett, R.C. (1993), 'Crew as Groups: Their Formation and Their Leadership', in E. Weiner, B. Kanki and R. Helmreich (eds), Cockpit Resource Management (San Diego, CA: Academic Press) 71-98.
29. Goguen, J., Linde, C. and Murphy, M. (1986), Crew Communications as a Factor in Aviation Accidents (Technical Memorandum No. A-86254) (Moffett Field, CA: National Aeronautics and Space Administration).
30. Grice, H.P. (1975), 'Logic and Conversation', in P. Cole and J.L. Morgan (eds), Syntax and Semantics Volume 3: Speech Acts (NY: Seminar Press) 225-42.
31. Grote, G. and Zala-Mezo, E. (2004), The Effects of Different Forms of Coordination in Coping with Workload: Cockpit versus Operating Theatre. Report on the psychological part of the project. GIHRE-Kolleg (Group Interaction in High Risk Environments) of the Daimler-Benz-Foundation (Zürich: Institut für Arbeitspsychologie).
32. Harrison, Y. and Horne, J.A. (1997), 'Sleep Deprivation Affects Speech', Sleep 20:10, 871-8.
33. Helmreich, R.L. (2005), 'What Crews Do: Context and Concepts of Threat and Error Management (TEM)', paper presented at the Third ICAO/IATA LOSA/TEM Conference, Kuala Lumpur, September 13.
34. Helmreich, R.L. and Davies, J.M. (1996), 'Human Factors in the Operating Room: Interpersonal Determinants of Safety, Efficiency and Morale', Clinical Anaesthesiology 10:2, 277-95.
35. Helmreich, R.L. and Foushee, C.H. (1993), 'Why Crew Resource Management? Empirical and Theoretical Bases of Human Factors Training in Aviation', in E.L. Weiner, B.G. Kanki and R.L. Helmreich (eds), Crew Resource Management (San Diego: Academic Press) 3-41.
36. Helmreich, R.L., Klinect, J.R. and Wilhelm, J.A. (1999), 'Models of Threat, Error, and CRM in Flight Operations', in R.S. Jensen (ed.), Proceedings of the 10th Annual International Symposium on Aviation Psychology (Columbus, OH: Ohio State University) 677-82.
37. Helmreich, R.L. and Merritt, A. (1998), Culture at Work in Aviation and Medicine: National, Organizational and Professional Influences (Aldershot, UK: Ashgate Publishing).
38. Helmreich, R.L. and Sexton, J.B. (2004), 'Group Interaction under Threat and High Workload', in R. Dietrich and T.M. Childress (eds), Group Interaction in Highrisk Environments (Burlington, VT: Ashgate Publishing) 9-23.
39. Kanki, B.G. and Foushee, H.C. (1989), 'Communication as Group Process Mediator of Aircrew Performance', Aviation, Space, and Environmental Medicine 60:5, 402-10.
40. Kanki, B.G. and Palmer, M.T. (1993), 'Communication and Crew Resource Management', in E. Weiner, B. Kanki and R. Helmreich (eds), Cockpit Resource Management (San Diego: Academic Press) 99-137.
41. Kayten, P.J. (1993), 'The Accident Investigator's Perspective', in E.L. Weiner, B.G. Kanki and R.L. Helmreich (eds), Cockpit Resource Management (San Diego: Academic Press) 283-314.
42. Keyton, J. (1999), 'Relational Communication in Groups', in L.R. Frey (ed.), The Handbook of Group Communication Theory and Research (Thousand Oaks, CA: Sage Publications) 192-222.
43. Klinect, J.R., Wilhelm, J.A. and Helmreich, R.L. (1999), 'Threat and Error Management: Data from Line Operations Safety Audits', in R.S. Jensen (ed.), Proceedings of the 10th International Symposium on Aviation Psychology (Columbus, OH: Ohio State University) 683-8.
44. Kluger, M. and Bullock, M. (2002), 'Recovery Room Incidents: A Review of 419 Reports from the Anaesthetic Incident Monitoring Study (AIMS)', Anesthesia 57:11, 1060-66.
45. Kohn, L., Corrigan, J. and Donaldson, M. (2000), To Err is Human: Building a Safer Health System (Washington, DC: National Academies Press).
46. Landrigan, C.P., Barger, L.K., Cade, B.E., Ayas, N.T. and Czeisler, C.A. (2006), 'Interns' Compliance with Accreditation Council for Graduate Medical Education Work-hour Limits', Journal of the American Medical Association 296:9, 1063-70.
47. Landrigan, C.P., Rothschild, J.M., Cronin, J.W., Kaushal, R., Burdick, E., Katz, J.T., Lilly, C.M., Stone, P.H., Lockley, S.W., Bates, D.W. and Czeisler, C.A. (2004), 'Effect of Reducing Interns' Work Hours on Serious Medical Errors in Intensive Care Units', New England Journal of Medicine 351:18, 1838-48.
48. Lauber, J.K. (1993), 'Foreword', in E.L. Weiner, B.G. Kanki and R.L. Helmreich (eds), Cockpit Resource Management (San Diego: Academic Press) xv-xviii.
49. Lauche, K., Ehbets-Müller, R. and Mbiti, K. (2001), 'Understanding and Supporting Innovation in Teams', Proceedings of International Conference on Engineering Design (Glasgow, UK: ICED) 395-402.
50. Lautman, L.G. and Gallimore, P.L. (1987), 'Control of Crew-caused Accidents: Results of a 12-operator Survey', in Airliner (Seattle: Boeing Commercial Airplane Co.) 1-6.
51. Leape, L., Bates, D., Cullen, D., Cooper, J., Demonaco, H.J., Gallivan, T., Hallisey, R., Ives, J., Laird, N., Laffel, G., Nemeskal, R., Petersen, L.A., Porter, K., Servi, D., Shea, B.F., Small, S.D., Sweitzer, B.J., Thompson, B.T. and Vander Vliet, M. (1995), 'Systems Analysis of Adverse Drug Events', Journal of the American Medical Association 274:1, 35-43.
52. Linde, C. (1988), 'The Quantitative Study of Communicative Success: Politeness and Accidents in Aviation Discourse', Language in Society 17:3, 375-99.
53. Lingard, L., Reznick, R., Espin, S., Regehr, G. and DeVito, I. (2002), 'Team Communications in the Operating Room: Talk Patterns, Sites of Tension, and the Implications for Novices', Academic Medicine 77:3, 232-7.
54. Loukopoulos, L.D., Dismukes, R.K. and Barshi, I. (2001), 'Cockpit Interruptions and Distractions: A Line Observation Study', in R. Jensen (ed.), Proceedings of the 11th International Symposium on Aviation Psychology (Columbus, OH: Ohio State University).
55. Mackenzie, C.F., Horst, R.L., Mahaffey, D.L. and the LOTAS Group (1993), 'Group Decision Making During Trauma Patient Resuscitation and Anesthesia', Proceedings of the 37th Annual Meeting of the Human Factors and Ergonomics Society (Santa Monica, CA: HFES) 372-6.
56. MacMillan, J., Paley, M.J., Levchuk, Y.N., Entin, E.E., Freeman, J.T. and Serfaty, D. (2001), 'Designing the Best Team for the Task: Optimal Organizational Structures for Military Missions', in M. McNeese, E. Salas and M. Endsley (eds), New Trends in Cooperative Activities: Understanding System Dynamics in Complex Environments (Santa Monica, CA: HFES) 284-99.
57. Miller, G.A., Galanter, E. and Pribram, K.H. (1960), Plans and the Structure of Behavior (NY: Holt, Rinehart and Winston).
58. Norman, D.A. (1981), 'Categorization of Action Slips', Psychological Review 88:1, 1-15.
59. NTSB (1972), Aircraft Accident Report: Allegheny Airlines, Inc. Allison Prop Jet Convair 340/440, N5832, New Haven, CT, June 7, 1971 (No. NTSB-AAR-72-20) (Washington, DC: NTSB).
60. NTSB (1973), Aircraft Accident Report: Eastern Airlines L-1011, N310EA, Miami, FL, Dec. 29, 1972 (No. NTSB-AAR-73-14) (Washington, DC: NTSB).
61. NTSB (1979), Aircraft Accident Report: United Airlines, MD-DC8-61, N8082U, Portland, OR, Dec. 28, 1978 (No. NTSB-AAR-79-7) (Washington, DC: NTSB).
62. NTSB (1982), Aircraft Accident Report: Air Florida, Inc., Boeing 737-222, N62AF, collision with 14th Street Bridge, near Washington national airport, Washington DC, January 13, 1982 (No. NTSB-AAR-82/08) (Washington, DC: NTSB).
63. NTSB (1986), Aircraft Accident Report: Delta Airline, Inc., Lockheed L-1011-385-1, N726DA, Dallas/Fort Worth International Airport, Texas, August 2, 1985 (NTSB report No. 86/05) (Washington, DC: NTSB).
64. NTSB (1991), Aircraft Accident Report: Avianca, The Airline of Colombia, Boeing 707-321B, HK2016. Fuel Exhaustion, Cove Neck, NY, January 25, 1990 (No. NTSB/AAR-91-04) (Washington, DC: NTSB).
65. NTSB (1994), A Review of Flightcrew-involved, Major Accidents of U.S. Air Carriers, 1978-1990 (NTSB report No. PB 94-917001, NTSB/SS-94/01) (Washington, DC: NTSB).
66. Orasanu, J. (1990), Shared Mental Models and Crew Decision Making (No. CSL 46) (Princeton, NJ: Cognitive Science Laboratory, Princeton University).
67. Orasanu, J. (1995), 'Evaluating Team Situation Awareness Through Communication', in D. Garland and M. Endsley (eds), Proceedings of International Conference on Experimental Analysis and Measurement of Situation Awareness (Daytona Beach: Embry-Riddle Aeronautical University Press).
68. Orasanu, J. and Fischer, U. (1992), 'Distributed Cognition in the Cockpit: Linguistic Control of Shared Problem Solving', Proceedings of the Fourteenth Annual Conference of the Cognitive Science Society (Hillsdale, NJ: Erlbaum) 189-94.
69. Orasanu, J. and McDonnell, L. (1999), 'How Do Flight Crews Detect and Prevent Errors? I. Explanations for Failures to Correct Errors', in R.S. Jensen (ed.), Proceedings of the 10th International Symposium on Aviation Psychology (Columbus, OH: Ohio State University).
70. Orasanu, J. and Salas, E. (1993), 'Team Decision Making in Complex Environments', in G.A. Klein, J. Orasanu, R. Calderwood and C.E. Zsambok (eds), Decision Making in Action: Models and Methods (Norwood, NJ: Ablex) 327-45.
71. Parker, J. and Coiera, E. (2000), 'Improving Clinical Communication: A View from Psychology', Journal of the American Medical Informatics Association 7:5, 453-61.
72. Perry, S.J., Wears, R.L., Anderson, B. and Booth, A. (2007), 'Peace and War: Contrasting Cases of Resilient Teamwork in Healthcare', paper presented at the Eighth International Naturalistic Decision Making Conference, Pacific Grove, CA.
73. Prince, C. and Salas, E. (1997), 'Situation Awareness for Routine Flight and Decision Making', International Journal of Cognitive Ergonomics 1:4, 315-24.
74. Reason, J. (1990), Human Error (Cambridge, UK: Cambridge University Press).
75. Ruffell Smith, H.P. (1979), A Simulator Study of the Interaction of Pilot Workload with Errors, Vigilance, and Decisions (No. NASA Technical Memorandum 78482) (Moffett Field, CA: NASA Ames Research Center).
76. Sundstrom, E., De Muse, K.P. and Futrell, D. (1990), 'Work Teams: Applications and Effectiveness', American Psychologist 45:2, 120-33.
77. Watzlawick, P., Beavin, J.B. and Jackson, D.D. (1967), Pragmatics of Human Communication: A Study of Interactional Patterns, Pathologies, and Paradoxes (New York: Norton and Company).
78. Wilson, R., Runciman, W., Gibberd, R., Harrison, B.T., Newby, L. and Hamilton, J.D. (1995), 'The Quality in Australian Health Care Study', The Medical Journal of Australia 163:9, 458-71.
79. Xiao, Y., Hunter, W.A., Mackenzie, C.F., Jeffries, N.J., Horst, R. and the LOTAS Group (1996), 'Task Complexity and Emergency Medical Care and its Implications for Team Co-ordination', Human Factors 38:4, 636-45.
80. Xiao, Y. and Mackenzie, C.F. (1998), 'Collaboration in Complex Medical Systems', Collaborative Crew Performance in Complex Operational Systems: NATO Human Factors and Medicine Symposium (Neuilly sur Seine: NATO) 4-10.
81. Xiao, Y., Moss, J., Mackenzie, C.F., Seagull, F.J. and Faraj, S. (2002), 'Transactive Responsibility Systems', Proceedings of the 46th Human Factors and Ergonomics Society Meeting (Santa Monica, CA: HFES) 1428-32.