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Patient Safety Improvement with Crew Resource Management : transformation from a blame culture to a learning cultureBive, Rolf, Enbom, Bo January 2017 (has links)
Background Being able to learn from mistakes is a vital aspect of nurse’s professionalism and increasing patient safety. With Crew Resource Management methodologies, aviation and other High Risk Organisations have succeeded in enabling learning cultures that should be applicable also to healthcare. Purpose The purpose was to describe how Crew Resource Management and the inherent learning culture could improve nurse’s professionalism and patient safety within the healthcare system. Method A literature overview based on database searches in CINAHL, PubMed and a manual search, resulting in 25 scientific articles analysed using an integrated analysis method and quality review. Results Crew Resource Management implementations have a positive effect on the nurse’s professional role and patient safety but have still not reached the full potential. Incident reporting is a key factor in providing feedback but still encounters barriers as a basis for pre-emptive learning. Identified barriers are not using Crew Resource Management components as a whole, a lack of feedback and an insufficient learning culture. Feedback is connected to nurse’s perception and situational awareness strengthening morale and professionalism. Conclusion Nurses professionalism and patient safety is dependent on being able to learn from mistakes which is a key aspect of Crew Resource Management. Learning is enabled by the reporting of mistakes in incident reporting systems without the fear of being punished. Improvements to both systems and the reporting culture are seen as needed, as-well as changes to the education system promoting reporting as part of an overall safety and learning culture.
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Airline Pilots in Recovery From Alcoholism: A Quantitative Study of Cognitive ChangeHamilton, Heather Christina 01 January 2016 (has links)
In order to perform their duties, airline pilots must have no clinical diagnosis of mental illness or any substance use disorder. However, provisions have been in place since the 1970s that provide for a return to work for airline pilots with alcohol problems. To date, over 5,000 airline pilots have undergone rehabilitation for Alcohol Use Disorder (AUD) and successfully returned to work. An important gap in the literature remains with regard to what extent improvements in cognitive performance may be experienced by airline pilots who complete treatment and to what extent age influences the amount of change. This study examined the archival data of 95 male Caucasian pilots who were assessed for cognitive performance shortly after entry to 30-day inpatient treatment and approximately 5 months later during the return to work evaluation. A nonexperimental within subjects design compared pre- and post-treatment scores on the Wechsler Adult Intelligence Scale-IV (WAIS-IV) full scale and 4 index scores as well as differences for age groups (25 to 44, 45 to 54, and 55 to 64). Repeated measures ANOVA revealed that there were significant gains on all WAIS-IV measures pre-post treatment for AUD. MANOVA results indicated no differences between age groups. These findings support current Federal Aviation Administration program practices with regard to returning airline pilots to work following rehabilitation and a sufficient period of abstinence. The potential of this study to promote the agenda of social change may be substantive for raising awareness of the cognitive deficits associated with AUD and how these may impact the safety of flight operations.
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Adopting the principles of ‘Crew Resource Management’ to the offshore drilling industryAhern, Dan Unknown Date (has links)
This report recommends a strategy for the introduction of aviation style Crew Resource Management (CRM) to the offshore drilling industry. The purpose of this study was to investigate ways CRM could be applied to the offshore drilling industry as a means of mitigating the risks of human error, and in particular risks to health and safety. Research has been conducted in accordance with accepted social science research methodologies. Key processes involved a formal literature review plus the formation of a Nominal Reference Group and application of the Delphi Technique as the primary data gathering method. Case studies have been used throughout this report to provide examples of key points and to illustrate the need for effective management of human error in both the aviation and drilling industries. Results from this study provided the basis for the development of a preferred implementation plan as a practical means for adopting the principles of CRM to the offshore drilling industry. Recommendations for furthering this work include the need to benchmark training as a means of providing better evidence that CRM leads to improved safety and operational performance, the need to develop a business plan to justify the cost and effort, the need to further involve key stakeholders in the process, and they need to solicit endorsement for this project from influential industry bodies.
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Flying is Dangerous - That is why it is so safe : Miscommunication in aviationThörnqvist, Christer January 2020 (has links)
In this essay one has been investigating some of the reasons why aviation incidents take place and also examine what strategies there are to minimize the risks - primarily regarding miscommunication which often seems to be a contributing element or a direct cause in aviation mishaps. The aim of this study is to highlight and raise awareness about this field of study from a communicative point of view.The study has been performed using qualitative interviews with pilots, Air Traffic Controllers and other professionals within the aviation industry. The research has been somewhat hampered by the outbreak of the COVID-19 pandemic but not to an extent that would have corrupted the findings.The key results have indicated that miscommunication still is a problem in the aviation industry, but less so on the local national stage than in a global perspective. Two particular occurrences that have been given extra attention are runway incursions and the use of Controller Pilot Data-Link Communications.One has established that there are technical systems available on the market to improve communication performance and that runway incursion is a problem that grows with the complexity of the airport environment. One has also been made aware of the fact that human factors can only be mitigated so far with technology. The principal question has been: How can Miscommunication in Aviation be reduced? / I denna uppsats har vi tittat på några av de bakomliggande orsakerna till att incidenter fortfarande sker inom trafikflyget samt undersökt vilka strategier som föreligger för att minimera dessa risker - primärt pga felkommunikation vilken ofta tenderar att vara en bakomliggande eller direkt utlösande faktor i flygolyckor. Syftet med denna studie är att uppmärksamma och öka medvetenheten om dessa fenomen från en kommunikativ synvinkel.Studien har genomförts medelst en kvalitativ intervjumetod med piloter, flygledare och andra initierade yrkesgrupper inom flygindustrin. Forskningen har hämmats något pga utbrottet av COVID-19 pandemin men inte i en sådan omfattning att resultatet har förvanskats.De huvudsakliga resultaten har indikerat att felkommunikation fortfarande är ett problem inom flygbranschen, men i en långt mindre omfattning på lokal nationell nivå än i ett globalt perspektiv. Två specifika företeelser som har getts extra uppmärksamhet är rullbaneintrång samt användandet av CPDLC (datalänk).Vi har konstaterat att det finns tekniska system på marknaden för att förbättra prestandan på kommunikationen samt att rullbaneintrång är ett problem som växer med flygplatsens storlek och komplexitetsgrad. Vi har också uppmärksammats på att den mänskliga faktorn endast delvis kan undanröjas med hjälp av teknologi. Den huvudsakliga fågeställningen har varit: Hur kan felkommunikation inom flyget reduceras
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