Evidence-based Evaluation on the Overseas Aviation Risk Management and Its Performance_Chinese Journal of Evidence-Based Medicine

Authors：

XIE Yu ¹ , WEN Jin ¹ , GAO Xiaofeng ¹ , SUN Ding ¹ , LI Youping ¹ , LIANG Xiaoxiao ¹ , ZHAN Xiaoqing ¹ , YANG Tiangui ² , WANG Yu ³ , ZHANG Zongjiu ³ , ZHAO Minggang ³ , LU Jun ⁴ , LIU Qilin ⁴

1. Evidence-based Medicine and Epidemiology Center, West China Hospital, Sichuan University, Chengdu 610041 China2. Department of Quality Management, West China Hospital, Sichuan University, Chengdu 610041 China3. Department of Medical Administration, Ministry of Health, Beijing 100044, China4. Chinese Medical Doctor Association, Beijing 100711, China;

Corresponding author：

Keywords：

Aviation risk; Medical risk; Risk management; Evidence-based review

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Objective 　To provide reference for medical risk management by systematically reviewing the hterature on aviation risk management abroad.
Methods 　We searched the SCOPUS database and related websites, and handsearched related journals, for literatures on the history, experience, and models of aviation risk management, and their relationship to medical risk management. Rationale and method of evidence-based science were used to appraise and analyze the included hterature.
Results 　Aviation and medical industry were both with the characteristics of high technology, high risk, and high professional. The aviation risk management system including the unique information reporting system, risk analyzing tools and models covered the whole process of information collecting, analyzing and managing, and with the emphasis on systematical construction.
Conclusions 　Medical risk management in China should base on its own characteristics, taking the following experiences from aviation risk management into account：（1） establishing incident and shght ~fistake reporting system, with management mechanism and legal support. Pilot experiments should be practiced in high-risk department; （2） developing a training model hke Crew Resources Management（ CRM）, emphasizing non-technical skills training; （3） reinforcing staff and environment management for the control of human-origin risk; （4） constructing database for better information collection and analysis, developing and using perspective analyzing tools; （5） assessing the safety culture of medical organization with the tools used by aviation industry, and taking the experience of aviation safety culture construction.

Citation： XIE Yu,WEN Jin,GAO Xiaofeng,SUN Ding,LI Youping,LIANG Xiaoxiao,ZHAN Xiaoqing,YANG Tiangui,WANG Yu,ZHANG Zongjiu,ZHAO Minggang,LU Jun,LIU Qilin. Evidence-based Evaluation on the Overseas Aviation Risk Management and Its Performance. Chinese Journal of Evidence-Based Medicine, 2006, 06(2): 131-138. doi: Copy

1.	http://www.boeing.com/news/techissues/pdf/statsum.pdf.
2.	Institute of Medicine,To err is human:building a safer health system Washington DC:National Academy Press; 2000.
3.	Reason J.Human error:model and management.BMJ,2000;320:768-770.
4.	ICAO,Annex 13.International Standards and Recommended Practices for Aircraft Accident and Incident Investigation.8th Edition,July 1994.
5.	Janic.M.An assessment of risk and safety in civil aviation.Journal of Air Transport Management,2005; 6 (1):43-50.
6.	Normra K.Managing risks in airline industry.Japan and the WorldEconomy,2003; 15:469-479.
7.	Barach P,Small SD.Reporting and preventing medical mishaps:les sons from non-medical near miss reporting systems.BM J,2000;320:759-763.
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9.	US Federal Aviation Authority,US FAR 91.25.Aviation Safety Reporting Program:Prohibition against use of reports for enforcement purposes; 1985.
10.	McIntyre GR.The application of system safety engineering and management techniques at the US Federal Aviation Administration (FAA) Safety Science,2002; 40 (1-4):325-335.
11.	Stoop JA.Accident investigations:Trends,paradoxes and opportuni ties.International Journal of Emergency Management,2003; 1 (2):170-182.
12.	Johnson CW.How will we get the data and what will we do with it then? Issues in the reporting of adverse healthcare events,Qual.Saf.Health Care,2003; 12; 64-67.
13.	Staender S.Incident reporting systems in medicine.Zeitschrifi furArztliche Fortbildung und Qualitatssicherung,2001; 95 (7):479-484.
14.	Stoop JA.Independent accident investigation:A modem safety tool.Journal of Hazardous Materials,2004; 111 (1-3):39-44.
15.	Lu AYL.Analysis of aviation occurrence using aviation safety community risk management model approach.Transactions of the Aeronautical and Astronautical Society of the Republic of China,2004; 36 (4):375 -382.
16.	Majumda A,Ochieng WY,Nalder P.Trend analysis of controllercaused airspace incidents in New Zealand,1994-2002.Transportation Research Record,2004; (1888):22 -33.
17.	Guohua L.Sunsan P,Yandong Q.Driving-while-intoxicated history as a risk marker for general aviation pilots.Accident Analysis and Prevention,2005; 37 (1):179-184.
18.	McFadden KL.Risk models for analyzing pilot-error at US airlines:A comparative safety study.Computers and Industrial Engineering,2003; 44(4):581 -593.
19.	Allen HW,Abate ML Work process analysis:a necessary step in the development of decision support systems.An aviation safety case study.Interacting with Computers,1999; 11 (6):623-643.
20.	Edkins GD.The INDICATE safety program:Evaluation of a meth od to proactively improve airline safety performance.Safety Science,1998; 30(3) 275-295.
21.	McFadden KL.Predicting pilot-error incidents of US airline pilots using logistic regression.Applied Ergonomics,1997; 28 (3):209 212.
22.	Wreathall J,Nemeth C.Assessing risk:the role of probabilistic riskassessment(PRA) in patient safety improvement.Qual.Saf.Health Care,2004; 13:206-212.
23.	Barnett A.Air safety:End of the golden age? Journal of the Opera tional Research Society,2001; 52(8):849 -854.
24.	Sachon M,Pate-Cornell E.Delays and safety in airline maintenance.Reliability Engineering and System Safety,2000; 67 (3):301-309.
25.	Hunter DR.Measurement of hazardous attitudes among pilots.International Journal of Aviation Psychology,2005; 15 (1):23-43.
26.	Conway GA,Mode NA,Berman MD.Flight safety in Alaska:Comparing attitudes and practices of high-and low-risk air carriers.Aviation Space and Environmental Medicine,2005; 76 (1):52-57.
27.	Thomson ME..Aviation risk perception:A comparison between experts and novices.Risk Analysis,2004; 24 (6):1585-1595.
28.	Thomas MJW.Predictors of threat and error management:Identification of core nontechnical skills and implications for training systems design.International Journal of Aviation Psychology,2004; 14 (2):207-231.
29.	Li G,Baker SP,Oing Y.Age,flight experience,and risk of crash involvement in a cohort of professional pilots.American Journal of Epidemiology,2003; 157 (10):874-880.
30.	Sicard B,Taillemite JP,Jouve E.Risk propensity in commercial and military pilots.Aviation Space and Environmental Medicine,2003; 74(8):879 -881.
31.	Goode JH.Are pilots at risk of accidents due to fatigue? Journal of Safety Research,2003 ;34 (3):309-313.
32.	Wenner CA,Drury CG.Analyzing human error in aircraft ground damage incidents.International Journal of Industrial Ergonomics,2000; 26 (2):177 -199.
33.	Daniel J.Crew resource management training-clinicians’ reactions and attitudes.AORN Journal,2005; 82(2):213-226.
34.	Latorella KA,Prabhu PV.A review of human error in aviation maintenance and inspection.International Journal of Industrial Ergonomics,2000; 26:133-161.
35.	Besco R O.Human performance breakdowns are rarely accidents:they are usually very poor choices with disastrous results.Journal of Hazardous Materials,2004; 115:155-161.
36.	Krulak DC.Human Factors in Maintenance:Impact on Aircraft Mis hap Frequency and Severity.Aviation Space and Environmental Medicine,2004; 75 (5):429-432.
37.	Bove T,AndersEn HB.The effect of an advisory system on pilots’go/no-go decision during take-off.Reliability Engineering and System Safety,2002; 75(2):179 -191.
38.	Wiegmann DA,Zhang H,Vonthaden TL.Safety culture:An integrative review.International Journal of Aviation Psychology,2004; 14(2):117 -134.
39.	Hudson P.Applying the lessons of high risk industries to health care.Qual.Saf.Health Care,2003;12:7 -12.
40.	Geller ES,Hickman JS,Pettinger CB.The Airline Lifesaver:A 17years analysis of a technique to prompt the delivery of a safety message.Journal of Safety Research,2004; 35:357-366.
41.	Wang Y.Establishing medical risk monitoring and early warning system for quality improvement and patient safety.Chinese Journal of Evidence-Bused Medicine,2006; 6 (1):1-2.王羽.建立医疗风险监测预警体系,提高医疗质量,保障病人安全中国循证医学杂志,2006;6(1):1～2.
42.	Cohen MR.Why error reporting systems should be voluntary.BMJ,2000; 320:728-729.
43.	Leape LL.Reporting of Adverse Events.N Engl Med,347 (20):1633-1638.
44.	Marx DA,Slonim AD.Assessing patient safety risk before the injury occurs:an introduction of sociotechnical probabilistic risk modeling in health care Qual.Saf.Health Care,2003; 12:33 -38.
45.	Leonard M,Graham S,Bonacum D.The human factor:the critical importance of effective teamwork and communication in providing safe care.Qual.Saf.Health Care,2004; 13:85 -90.
46.	Thomas EJ,Sherwood GD,Helmreich RL.Lessons from aviation:teamwork to improve patient safety.Nursing Economics,2003; 21 (5):241 -244.
47.	Pape TM.Applying airline safety practices to medication administration.Medsurg Nursing,2003; 12(2):77-95.

1. http://www.boeing.com/news/techissues/pdf/statsum.pdf.
2. Institute of Medicine,To err is human:building a safer health system Washington DC:National Academy Press; 2000.
3. Reason J.Human error:model and management.BMJ,2000;320:768-770.
4. ICAO,Annex 13.International Standards and Recommended Practices for Aircraft Accident and Incident Investigation.8th Edition,July 1994.
5. Janic.M.An assessment of risk and safety in civil aviation.Journal of Air Transport Management,2005; 6 (1):43-50.
6. Normra K.Managing risks in airline industry.Japan and the WorldEconomy,2003; 15:469-479.
7. Barach P,Small SD.Reporting and preventing medical mishaps:les sons from non-medical near miss reporting systems.BM J,2000;320:759-763.
8. ODEGARD S.Safety management in civil aviation a useful method for improved safety in medical care? Safety Science Monitor,2000; 4(1):1-12.
9. US Federal Aviation Authority,US FAR 91.25.Aviation Safety Reporting Program:Prohibition against use of reports for enforcement purposes; 1985.
10. McIntyre GR.The application of system safety engineering and management techniques at the US Federal Aviation Administration (FAA) Safety Science,2002; 40 (1-4):325-335.
11. Stoop JA.Accident investigations:Trends,paradoxes and opportuni ties.International Journal of Emergency Management,2003; 1 (2):170-182.
12. Johnson CW.How will we get the data and what will we do with it then? Issues in the reporting of adverse healthcare events,Qual.Saf.Health Care,2003; 12; 64-67.
13. Staender S.Incident reporting systems in medicine.Zeitschrifi furArztliche Fortbildung und Qualitatssicherung,2001; 95 (7):479-484.
14. Stoop JA.Independent accident investigation:A modem safety tool.Journal of Hazardous Materials,2004; 111 (1-3):39-44.
15. Lu AYL.Analysis of aviation occurrence using aviation safety community risk management model approach.Transactions of the Aeronautical and Astronautical Society of the Republic of China,2004; 36 (4):375 -382.
16. Majumda A,Ochieng WY,Nalder P.Trend analysis of controllercaused airspace incidents in New Zealand,1994-2002.Transportation Research Record,2004; (1888):22 -33.
17. Guohua L.Sunsan P,Yandong Q.Driving-while-intoxicated history as a risk marker for general aviation pilots.Accident Analysis and Prevention,2005; 37 (1):179-184.
18. McFadden KL.Risk models for analyzing pilot-error at US airlines:A comparative safety study.Computers and Industrial Engineering,2003; 44(4):581 -593.
19. Allen HW,Abate ML Work process analysis:a necessary step in the development of decision support systems.An aviation safety case study.Interacting with Computers,1999; 11 (6):623-643.
20. Edkins GD.The INDICATE safety program:Evaluation of a meth od to proactively improve airline safety performance.Safety Science,1998; 30(3) 275-295.
21. McFadden KL.Predicting pilot-error incidents of US airline pilots using logistic regression.Applied Ergonomics,1997; 28 (3):209 212.
22. Wreathall J,Nemeth C.Assessing risk:the role of probabilistic riskassessment(PRA) in patient safety improvement.Qual.Saf.Health Care,2004; 13:206-212.
23. Barnett A.Air safety:End of the golden age? Journal of the Opera tional Research Society,2001; 52(8):849 -854.
24. Sachon M,Pate-Cornell E.Delays and safety in airline maintenance.Reliability Engineering and System Safety,2000; 67 (3):301-309.
25. Hunter DR.Measurement of hazardous attitudes among pilots.International Journal of Aviation Psychology,2005; 15 (1):23-43.
26. Conway GA,Mode NA,Berman MD.Flight safety in Alaska:Comparing attitudes and practices of high-and low-risk air carriers.Aviation Space and Environmental Medicine,2005; 76 (1):52-57.
27. Thomson ME..Aviation risk perception:A comparison between experts and novices.Risk Analysis,2004; 24 (6):1585-1595.
28. Thomas MJW.Predictors of threat and error management:Identification of core nontechnical skills and implications for training systems design.International Journal of Aviation Psychology,2004; 14 (2):207-231.
29. Li G,Baker SP,Oing Y.Age,flight experience,and risk of crash involvement in a cohort of professional pilots.American Journal of Epidemiology,2003; 157 (10):874-880.
30. Sicard B,Taillemite JP,Jouve E.Risk propensity in commercial and military pilots.Aviation Space and Environmental Medicine,2003; 74(8):879 -881.
31. Goode JH.Are pilots at risk of accidents due to fatigue? Journal of Safety Research,2003 ;34 (3):309-313.
32. Wenner CA,Drury CG.Analyzing human error in aircraft ground damage incidents.International Journal of Industrial Ergonomics,2000; 26 (2):177 -199.
33. Daniel J.Crew resource management training-clinicians’ reactions and attitudes.AORN Journal,2005; 82(2):213-226.
34. Latorella KA,Prabhu PV.A review of human error in aviation maintenance and inspection.International Journal of Industrial Ergonomics,2000; 26:133-161.
35. Besco R O.Human performance breakdowns are rarely accidents:they are usually very poor choices with disastrous results.Journal of Hazardous Materials,2004; 115:155-161.
36. Krulak DC.Human Factors in Maintenance:Impact on Aircraft Mis hap Frequency and Severity.Aviation Space and Environmental Medicine,2004; 75 (5):429-432.
37. Bove T,AndersEn HB.The effect of an advisory system on pilots’go/no-go decision during take-off.Reliability Engineering and System Safety,2002; 75(2):179 -191.
38. Wiegmann DA,Zhang H,Vonthaden TL.Safety culture:An integrative review.International Journal of Aviation Psychology,2004; 14(2):117 -134.
39. Hudson P.Applying the lessons of high risk industries to health care.Qual.Saf.Health Care,2003;12:7 -12.
40. Geller ES,Hickman JS,Pettinger CB.The Airline Lifesaver:A 17years analysis of a technique to prompt the delivery of a safety message.Journal of Safety Research,2004; 35:357-366.
41. Wang Y.Establishing medical risk monitoring and early warning system for quality improvement and patient safety.Chinese Journal of Evidence-Bused Medicine,2006; 6 (1):1-2.王羽.建立医疗风险监测预警体系,提高医疗质量,保障病人安全中国循证医学杂志,2006;6(1):1～2.
42. Cohen MR.Why error reporting systems should be voluntary.BMJ,2000; 320:728-729.
43. Leape LL.Reporting of Adverse Events.N Engl Med,347 (20):1633-1638.
44. Marx DA,Slonim AD.Assessing patient safety risk before the injury occurs:an introduction of sociotechnical probabilistic risk modeling in health care Qual.Saf.Health Care,2003; 12:33 -38.
45. Leonard M,Graham S,Bonacum D.The human factor:the critical importance of effective teamwork and communication in providing safe care.Qual.Saf.Health Care,2004; 13:85 -90.
46. Thomas EJ,Sherwood GD,Helmreich RL.Lessons from aviation:teamwork to improve patient safety.Nursing Economics,2003; 21 (5):241 -244.
47. Pape TM.Applying airline safety practices to medication administration.Medsurg Nursing,2003; 12(2):77-95.

Chinese Journal of Evidence-Based Medicine

Evidence-based Evaluation on the Overseas Aviation Risk Management and Its Performance

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