Threat and Error Management – A Key Component of a Safety Management System
The Threat and Error Management (TEM) model is the scaffolding upon which High Reliability Teams (HRTs), and ultimately High Reliability Organizations (HROs), are built.
Identifying Threats (any condition or event beyond the influence of the team that increases operational complexity), Errors (actions or inactions by the team that lead to deviations from intentions or expectations and reduce the margins of safety), and Undesired States (Threat/Error-induced states that clearly reduces safety margins) during normal activities and then linking the management or mismanagement of Threats, Errors, and Undesired States provides a more complete understanding of real-world operations.
Before TEM, aircrews did not have fully actionable trigger mechanisms to apply Crew Resource Management (CRM) skills and did not have a standardized framework for identifying and responding to unanticipated situations that increase risk. TEM provided this framework, allowing aircrews to identify threats, manage threats before they become errors, mitigate errors that still occur, and recover more quickly from reduced safety margins before an accident or mishap occurs. Air Force Manual 11-290, Cockpit/Crew Resource Management and Threat & Error Management Program, notes that “Threat and Error Management is a key component of a combined effort to identify and manage operational threats and human errors so as to ensure mission success” and TEM training begins with initial Air Force flight training and is continuously developed throughout their career!
”“Threat and Error Management is the active process of proactively managing the expected and unexpected situations that arise every day in complex settings,” said Dr. Stephen Powell, CEO of Synensys. “A robust learning cycle occurs when operators debrief their teams and submit voluntary safety reports using the TEM framework.”
Dr. Stephen Powell
Line Operations Safety Audit (LOSA) by SafeSight is an effective way to measure TEM performance within high-risk operational settings. With proper customization, Threat and Error Management training applied to clinical operations can improve patient safety outcomes. Just as with the aviation industry, clinical HRTs can utilize TEM training combined with a foundational TeamSTEPPS® (Team Strategies & Tools to Enhance Performance and Patient Safety) program to manage threats, prevent and mitigate errors, and avoid undesired patient states…ultimately reducing preventable harm. Recently, in coordination with USAF Air Mobility Command, Synensys conducted the first-ever Aeromedical Evacuation (AE) LOSA during actual patient transports leading to new operational insights paving the way for continuous process/performance improvement across USAF AE! Additionally, Synensys has incorporated TEM into HRT training conducted in healthcare settings such as perioperative services.
”“Medical professionals currently employ aspects of threat and error management but typically do not do so in a structured and team-based fashion” notes Dr. Daniel Wyman, Synensys’ Chief Medical Officer. “Formal TEM training and application within clinical operations will improve clinical quality and patient safety and decrease harm.”
Dr. Daniel Wyman
Synensys, headquartered in Peachtree City, Georgia, is a trusted leader in safety management technology and performance improvement for Federal, Military, Commercial, and international organizations since 2005. The Synensys team consists of seasoned safety and quality professionals in medicine and aviation, with expertise in change management, human factors, systems strengthening, strategy, learning, gap analyses, and safety performance analytics.
