Original ResearchAnalyzing Communication Errors in an Air Medical Transport Service
Introduction
Air medical transport (AMT) is a complex process that requires the coordination of aircraft and highly skilled professionals to transport critically ill or injured patients to definitive care. Failure to communicate effectively can result in poor coordination, increased errors, and adverse events. Research has shown poor communication to be a significant factor in adverse events in aviation,1, 2 health care,3, 4 and AMT.5 To prevent adverse events or mitigate their impact, organizations use quality and safety management systems for reporting issues, reviewing events, and reducing risks. Although poor communication is recognized as a key factor in adverse events, there are no standard frameworks or ontologies for quality and safety management systems to classify and analyze communication issues. Therefore, it is difficult to provide effective indicators for quality improvement. As a result, organizations develop custom reporting systems that often lack sufficient detail or usefulness for analyzing communication errors.
This study had 3 purposes: to determine the frequency of AMT communication errors reported within an AMT quality and safety management system, to analyze how staff classified communication errors, and to analyze communication errors using Clark's framework of communication.
Section snippets
Study Site
The setting for this study is an AMT service that provides adult, pediatric, and neonatal transport services. Patient transport is provided by rotor wing, fixed wing, ground ambulance, or any combination. This transport service averages approximately 11 patient transfers per day, with roughly half being pediatric/neonatal and half being adult. The majority of transports are interfacility transfers rather than scene flights.
Study Period
The study period was January 1, 2009, to December 31, 2009.
Theoretic Framework of Communication
The theoretic
Research Question 1: How Often Are Communication Errors Evident in Quality and Safety Assurance Reports?
Of the 278 reports reviewed, 58 had evidence of a communication error (21%). Table 6 provides the distribution of reports with communication errors by service and mode, whereas Table 7 provides the distribution of reports reviewed by service and mode.
Chi-square analysis showed no statistically significant differences between services (P = .810) or mode of transport (P = .328) when comparing the proportion of communication errors versus the proportion of reports submitted. Communication errors
Discussion
Miscommunication can lead to disastrous events in AMT. The accident report by the National Transportation and Safety Board of the mid-air collision of 2 medical transport helicopters in Flagstaff, AZ, on June 29, 2008, found that poor communication was a causal factor.13 The key objectives of this study were to analyze quality assurance reports to determine the frequency, types, and distribution pattern of communication errors within a theoretic framework.
At Life Flight, pilots, medical crew,
Conclusion
Current quality and safety assurance reporting systems may fail to identify key sources of communication errors because the reporting structure lacks sensitivity and specificity around these issues. The most frequent analysis asked of safety management systems is “How many and of what type?” Our results show that querying our quality and safety assurance reporting system for communication-related triggers would likely miss most communication errors. Although sensitivity could be increased by
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