• Nicole Powell-Dunford, Patricia Deuster, Mark McPherson, and Steven J Gaydos.
• Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda MD 20814.
• Mil Med. 2020 Jun 8; 185 (5-6): e616-e624.

IntroductionIn this research, the authors attempted to ascertain whether or not the Root Cause Analysis Event Support and Engagement Team (RESET) investigates the use of U.S. Army aviation-based techniques by staff members or organizations in which serious obstetrical events have occurred. Root cause analysis (RCA), originating in the manufacturing and engineering sectors, attempts to elucidate an underlying cause of a problem. Most recently, this process has been applied to the investigation of medical error. RESET was established in order to perform centralized investigation of significant medical error within U.S. Army medical and dental treatment facilities based on request from a hospital commander or general officer. Significant obstetric events are high profile, discussed in multiple safety forums, and an area of close RESET focus. Yet it is unclear if RESET investigates the use of aviation-based techniques by staff and/or organizations involved in serious obstetrical events. Therefore the present survey study was conducted.Materials And MethodsA structured, anonymous, voluntary survey was fielded to RESET staff in order to assess whether or not the RESET investigates the use of aviation-based techniques by staff members or organizations in which serious obstetrical events have occurred.ResultsFive of six members of this small team completed the survey. Prebriefs, debriefs, and checklist use were consistently investigated. The employment of a sterile cockpit, first-name introductions, annual check ride, and emergency procedure rehearsal were infrequently investigated.ConclusionObstetric RESET investigations inconsistently ascertain whether or not some of the aviation-based techniques are utilized by staff members or organizations in which serious obstetrical events have occurred. Standardization of investigative procedures and education directed at under-investigated practices may optimize medical investigation using proven tenets of an aviation-based approach.© The Author(s) 2020. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

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