1. NASA Model of “Threat and Error” in Pediatric Cardiac Surgery: Patterns of Error Chains 
Edward Hickey, MD, FRCSC, Eric Pham-Hung, HBSc, Yaroslavna Nosikova, JD, MASc, Fredrik Halvorsen, MD, PhD, Michael Gritti, HBSc, Steven Schwartz, MD, FRCPC, Christopher A. Caldarone, MD, FRCSC, Glen Van Arsdell, MD, FRCSC 
The Annals of Thoracic Surgery 
Volume 103, Issue 4, Pages (April 2017)
DOI: /j.athoracsur
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

2. Fig 1
Flight plan infographic depicting a child’s inpatient perioperative journey. Children are tracked from the point of admission. Risk is the y-axis, and time is the x-axis. Depiction of risk is figurative and not quantitative. Various threats (T), errors (E), and unintended patient states (U) are tracked on the graphs, and linked together if related. Permanent outcomes (complications persisting beyond discharge) and deaths are also documented. (CPB = cardiopulmonary bypass duration; CVL = central venous line; ECMO = extracorporeal membrane oxygenator; ICU = intensive care unit; RVSP = right ventricular systolic pressure; TEE = trans-esophageal echocardiogram; VSD = ventricular septal defect; XC = aortic cross clamp duration.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

3. Fig 2
Threat-and-error model proposed by Helmreich [10, 13] and used by the Federal Aviation Administration [9]. Immediate threats (T) are factors outside the control of the cockpit crew (threats come at the crew) and increase the risk of an error (E) being made (errors come from the crew). Errors may be recognized and mitigated, but a consequential error leads to an unintended state (U). Unintended states may be benign if well managed, but are themselves risk factors for additional errors or unintended states. This chain of error or unintended state leads to progressive loss of safety margins and is a prelude to a catastrophic outcome.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

4. Fig 3
Schematic flight plan infographic illustrating the expected deescalation in risk (black line). Failed deescalation in risk (dashed line) is an aberration in this expected sequential reduction in risk level. (E = error; ICU = intensive care unit; OR = operating room; T = threat; U = unintended state.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

5. Fig 4
(A) Number of amplifying errors influencing chains of error or unintended clinical state and (B) error category of amplifying errors.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions