Patient safety: A brief but spirited history

Communication, the vehicle for transferring evidence, creating information and developing knowledge, will be highlighted as a mechanism to enhance teamwork in a reliable, safe way. Communication is critical for individuals and particularly teams in high-risk domains, and has been suggested as the most workable concept to port from aviation to healthcare to improve safety. Individual and team sensemaking as an EI&K application may be easier to first define in an aviation context. Crew Resource Management (CRM) emphasizes using all resources, human and machine, to safely operate a flight. High Reliability Organizations (HROs) manage high-risk, high-consequence processes with low rates of failure and harm. Two important traits of HROs are resilience and sensemaking. Aviation is ahead of healthcare in determining system weaknesses, but that sector also has not advanced in the application of HRO and safety principles in terms of pilots use of information and failures that could result from incomplete or unclear information.