L.Connell 4/05 Cross-Industry Application of an Aviation Model for Confidential Reporting 2005 Michigan Health & Safety Coalition Patient Safety Conference Dearborn, MI April 7, 2005 Linda Connell, Director, NASA Aviation Safety Reporting System

L.Connell 4/05 Ames Research Center Dryden Flight Research Center Langley Research Center Glenn Research Center Jet Propulsion Laboratory Johnson Space Center Marshall Space Flight Center Goddard Space Flight Center Kennedy Space Center NASA Centers

L.Connell 4/05 NASA Ames Research Center 30-year history of Aviation Human Factors Research Human Error, Decision-making, Fatigue, CRM NASA Center of Excellence in Information Technology Data mining and visualization tools High reliability computing Human-Computer Interaction Proven track record as independent, competent and trustworthy manager of safety data: Aviation Safety Reporting System (ASRS) 29 years of experience - 640,000 reports NEVER a single breach of confidence

HUMAN PERFORMANCE CONTRIBUTION TO ERROR

L.Connell 4/05 Aviation Safety Reporting System (ASRS)

L.Connell 4/05 Aviation Tragedy Leads to Genesis of ASRS TWA 514, December 1, 1974

L.Connell 4/05 Overview Summary ASRS established in 1976 as an independent, confidential, voluntary reporting system for aviation at NASA with FAA offering “immunity” to reporters. One of the first lines of defense in identifying safety issues NASA chosen as “Honest Broker” Located at NASA Ames Research Center due to Aviation Human Factors expertise and research—it was recognized that approximately 70% of all accidents are human factors related. ASRS database is a national asset of U.S. aviation safety data

L.Connell 4/05 Guiding Principles VOLUNTARY PARTICIPATION Aviation personnel voluntarily submit reports concerning events related to safety for the purpose of system alerting, understanding and learning CONFIDENTIALITY PROTECTION Protection of identity is provided by NASA through de- identification of persons, companies, and any other information NON-PUNITIVE FAA will not use, nor will NASA provide, any report submitted for inclusion under ASRS guidelines or information derived therein for use in any disciplinary or other adverse action. (Advisory Circular 0046D)

L.Connell 4/05 Stakeholders

Normal Operations Incidents Injury Accidents Fatal Accidents ASRS is Complementary to Other Systems of Reporting Event Occurrences { FAA & NTSB { ASRS Precursors

L.Connell 4/05 ASRS PURPOSE Identify Deficiencies and Discrepancies Provide Data for Planning and Improvements ALERTSPRODUCTS

L.Connell 4/05 ASRS Expert Analyst Staff Aviation Operational Expert Analysts perform initial screening, identification of alerts, initial analyses, database coding, and special studies (e.g., structured callback interviews and consultation on special safety topics). Expert Analysts are retired air carrier pilots (Part 121 and 135), retired air traffic controllers, retired maintenance technicians, general aviation pilots, and flight attendants. A minimum of 10 years aviation experience required. Years of aviation experience of the current analyst staff totals to approx. 390 yrs. An average of 35.5 yrs experience in aviation.

L.Connell 4/05 Annual ASRS Report Intake ASRS Report Intake An Increase of 70% Since 1988 Averaging 2,900 Reports Per Month 145 per working day Total 2003 Report Intake = 34,043 Reports Intake projected to exceed 34,000 in 2004

L.Connell 4/05 INCIDENT REPORTER DISTRIBUTION

L.Connell 4/05 Products

ASRS Genesis of Human Factors Research at NASA Ames

L.Connell 4/05 ASRS Database Alert Messages Researc h FAA & NTSB Quick Responses Monthly Safety Newsletter Quarterly Safety Bulletin Incident Reports Database Search Requests CD ROM ASRS PRODUCTS & SERVICES FOR THE AVIATION COMMUNITY

L.Connell 4/05 PUBLICATIONS CALLBACK is ASRS's award-winning monthly safety bulletin that began publication in It has an estimated readership of more than 150,000. Over 260 issues have been published and distributed throughout the U.S. and to the international aviation community. All issues are available for download at the ASRS website. DIRECTLINE Is another award-winning ASRS publication. This safety journal has an estimated distribution / readership of 20,000. Ten issues have been published since 1991 with a baseline of three to five articles per issue. All issues are available for download at the ASRS website.

ASRS Home Page ASRS Database Access at FAA NASDAC Site:

L.Connell 4/05 International Confidential Aviation Safety Systems ICASS

L.Connell 4/05 ASRS - Model for Other Operational Systems There has been growing interest from a variety of disciplines desiring the safety benefits realized in aviation. Numerous organizations have requested assistance from the ASRS in creating reporting systems designed to help them understand and learn about their own systems.

L.Connell 4/05 CROSS-INDUSTRY APPLICATION NASA and Department of Veterans Affairs Patient Safety Reporting System (PSRS)

The VA’s Efforts Towards Patient Safety Improvements Vision for Change Initiated National Patient Safety Partnership VA National Center for Patient Safety Established (NCPS) 2000 The VA Patient Safety Changes Were Initiated in 1995 The PSRS is an Expansion of the VA’s Commitment to Quality and Safety Development Of NASA/VA Patient Safety Reporting System (PSRS) Patient Safety Centers of Inquiry Established 1995 Expert Advisory Panel Meetings

INSTITUTE OF MEDICINE REPORT Released 1999

Medical Performance Factors

VA and NASA Launch Agreement for PSRS May ‘00 - Interagency Agreement signed between NASA and Department of Veterans Affairs –Dr. Thomas Garthwaite, Under Secretary of Health –Dr. Henry McDonald, Director, NASA Ames Research Center NASA Ames Research Center, Moffett Field, CA and VA National Center for Patient Safety, Ann Arbor, MI are collaborating to maximize patient safety efforts –Dr. Jim Bagian, Director of NCPS –Ms. Linda Connell, Director of PSRS

Event Chain Operational System Human Performance System Improvement & Learning Incidents & Close Call Events Sentinel Events

VA Staff Invited to Participate Any VA staff or personnel working in VA facilities are invited to submit voluntary reports concerning medical safety Physicians Nurses Laboratory Radiology Pharmacy Rehabilitation Dietitians Support Staff Others

PSRS Reports – Reporter Types * *As of March 2004

PSRS Reports – Anomaly Types * *As of March 2004

Feedback to VA Reporting Community 5 Patient Safety Bulletins (PSBs) have been issued since April Issues of FEEDBACK – PSRS Quarterly Newsletter – distributed since August 2002

L.Connell 4/05 Linking Risk Assessment with Risk Management

L.Connell 4/05 Encompasses: Risk Assessment Risk Mitigation Evaluation of Residual Risk Risk Acceptance Risk Management Confidential Reporting Model Has Specific Contributions to: Risk Assessment NASA NPG

L.Connell 4/05 Nine Steps of Risk Assessment 1)System Characteristics 2)Threat Identification 3)Vulnerability Identification 4)Control Analysis 5)Probability Determination 6)Impact Analysis 7)Risk Determination 8)Control Recommendations 9)Results Documentation NASA NPG

Human Factors, Risk Identification, Safety Assessment, Insights Alerting Messages, Special Studies Charles E. Billings, MD. (1998). “The NASA Aviation Safety Reporting System: Lessons Learned from Voluntary Incident Reporting.” In Proceedings of National Patient Safety Foundation Conference, Enhancing Patient Safety and Reducing Errors in Health Care, Chicago (pp ).

L.Connell 4/05 SUMMARY WHY CONFIDENTIAL REPORTING WORKS When organizations want to learn more about the occurrence of events, the best approach is simply to ask those involved. People are generally willing to share their knowledge if they are assured: Their identities will remain protected There is no disciplinary or legal consequences A properly constructed confidential, voluntary, non-punitive reporting system can be used by any person to safely share information

L.Connell 4/05 WHY CONFIDENTIAL REPORTING WORKS Confidential reporting systems have the means to answer the question why - why a system failed, why a human erred Incident/event data is complementary to the data gathered by other monitoring systems

L.Connell 4/05 Confidential Reporting Can - Provide the “Big Picture” Most other data sources lack the ability to capture the information that this type of reporting receives. -Reporting from a broad population of system users -Reporting covers the full spectrum of safety concerns Reporting system can target specific populations for special study and expanded information gathering -Structured Callback Studies -Routine telephone callback -Special Studies

L.Connell 4/05 Thank you for your interest and attention