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Cheeki Rafiki, Air France 447 & Pediatric Heart Surgery

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Heart + Lung Joint Rounds


“Cheeki Rafiki, Air France 447 and pediatric heart surgery: Chasing the culture of 6-sigma industries”


Thursday, September 10, 2015
8:00 a.m. – 9:00 a.m.

St. Paul’s Hospital, 1081 Burrard Street, Vancouver BC in the Cullen Family Lecture Theatre

with video link to:

VGH – DCHH Main Lecture Theatre
BC Children’s Hospital – Rm 1F11
Royal Jubilee Hospital – DT 3505
Nanaimo Regional General Hospital – Island Health Rm 2050



Dr. Edward Hickey, MD, FRCSC
SickKids – The Hospital for Sick Children
University of Toronto
Division of Cardiovascular Surgery



In August 2013, a captain and first officer on a British long-haul commercial airliner reported that they had both unintentionally – and simultaneously – fallen asleep mid-flight. They reported this episode freely and without repercussion because the culture of aviation and other high-stakes industries is geared towards a “systems approach” to error.

The systems approach to error began with NASA in the 1970s. The “threat and error” model that emerged is still in use by the FAA today. We have applied this model to our paediatric heart surgery program. Every child has a “flightplan” that is reviewed weekly in an open forum for potential threats, errors and unintended clinical deviations. Error rates and patterns of error chains are similar to those found in commercial cockpits. Death or neurologic injury almost always results from chains of error and unplanned deviations from the expected clinical journey. High-stakes medical personnel would likely benefit from training in error recognition and containment akin to “crew resource management”, that is mandatory for all commercial pilots.



Edward is a pediatric cardiac surgeon at Sick Kids, Toronto, and is a faculty member of the University of Toronto Department of Surgery. He was the 3rd Kirklin-Asburn fellow with the Congenital Heart Surgeons’ Society, and subsequently joined Sick Kids faculty in the division of cardiovascular surgery in 2012. Edward’s academic interests lie in: 1) parametric time-related outcomes analyses, 2) brain injury and neuroprotective strategies in congenital heart disease and 3) understanding the “human factor” aspect of surgical outcomes. Regarding the latter, Edward has applied models of human error derived from the aviation industry and is interested in strategies that can break cycles of dangerous error and unintended clinical states.


Special thanks to Providence Health Care for supporting this lecture.