Patient safety is harder than aviation safety

Comments (29)

• Burl Stamp June 14, 2011 12:12 PM

  Very well said, Jeff. While there is much we can continue to learn from aviation, nuclear power, and other industries that have made significant progress in safety, health care is indeed harder.

  In particular, the healthcare environment makes communication across the team and with our customers extremely challenging. Clinical professionals must process a relatively high number of dissimilar transactions every hour in an environment where the hierarchy is well established and sometimes stifling. Layer on top of that the emotionally charged issues and situations clinical professionals are expected to handle with amplomb every day and you've described a milieu that makes implementing seemingly straightforward, standardized safety practices very difficult.

• Dr. Lawrence Robinson July 14, 2011 11:23 AM

  Excellent insight and well outlined. This is the comparison that should be the basis for deciding that a "safety quality program" is working rather than the typical platitudes about aviation checklists as the source for error reduction in medicine.

  Given the number of diagnoses, physicians, nursing and non-nursing healthcare providers, number of available therapeutics being applied against a large number of patients each with unique metabolisms/genetics/variable response rates to the treatment plan, then the total number of interactions and possible events are exponentially greater than any airline process. Hopefully GE can learn to design safety systems that are relevant.

• George Cybulski,MD,MBA July 14, 2011 2:40 PM

  Jeff, I couldn't agree more. The safety checklist in the OR is rudimentary at best and once "plane takes off", ie, the operation starts, only the surgeon has the flight plan in his head where no one of the remainder of the team has access. Patients aren't airplanes and operating rooms aren't airports.

• Lynne July 14, 2011 9:29 PM

  Couldn't agree more. Operating complex pieces of equipment is one small part of what we do as medical care providers. Human beings are far more complex (and wondrous) machines.
  So while comparisons may be fun, they aren't necessarily of great help in real healthcare situations. Thanks for trying though.

• AnandaPadmanabhan P July 14, 2011 11:44 PM

  True facts. Appreciate the points compared. When aviation avoids people getting into danger,healthcare saves people from danger. Both ways, life safety is predominantly important.

• sabina sanguineti July 15, 2011 2:26 AM

  Hi Jeff, I agree with you. Two years ago I put this same question to Charles Vincent who was here in Italy for a conference. I asked him if he thought there were "cognitive differences" between aviation and health that could make more difficult for us to "learn from errors". Vincent said there were no "cognitive differences" but the greatest difference is that in aviation they already have most the processes under control, that is they already "mesure" all the processes and have still a little fraction of uncertainty. We don't!
  Sabina Sanguineti Clinical Risk Manager Hospital of Livorno

• Dr Pramathesh Panchal July 15, 2011 3:09 AM

  I very closely agree with your comments sir, yet there are other points too to be considered,viz. 1. A patient is being taken care of by at a time one particular medical professional only, whereas the passengers while in air are being looked after by those who may not fully conversant with the job,2.the patient is stationary while being treated or may be ambulatory if being evacuated but the passengers are always on the board and in the air where the facilities may not be available and they are in the hands of their fate? or god?,plus less of Oxygen,BP changes due to scare etc. all these also to be considered.

• Dev Raheja,author "Safer Hospital Care" July 15, 2011 6:19 AM

  Jeff, I find it difficult to agree. An earoplane like Boeing 777 has over a million components, then there are other stakeholders in in aviation safety besides pilots including flight attendants who can make mistakes, air traffic controllers, thunders, lightnings, baggage handlers, communications software with millions of lines of code, terrorists, and millions of passwengers who can carry dangerous thing. Yes, patient safety is just as hard.

• Dennis Blass July 15, 2011 7:44 AM

  I concur with half your premise, healthcare security is harder than aviation security. It is as you say a numbers game. I do not concur that the aviation sector has done it well.

  Aviation security took the wrong approach from the start. It relied on a small group of people armed with intrusive procedures and technology to enforce security on users. It was based on fear, not knowledge. It is a fundamentally wrong approach.

  A better approach is to 1. Gain the trust of the traveling public and earn their respect and cooperation; 2. Use a risk-based approach; 3. Share and use intelligence to drive security practices; 4. Transparent evaluation of security practices enabling continual improvement; 5. Use technology where it will do the most good.

• Dennis Blass July 15, 2011 8:13 AM

  I concur with half your premise. Hospital security is more difficult than aviation security. It is as you say, a numbers game. I cannot agree that aviation security is done well. In fact I would argue that aviation security is an excellent model from which to learn what to avoid.

  Aviation is a process approach that is designed not to fail. The problem is that does fail, several times a day according to DHS statistics. In addition, the aviation security process is intrusive, expensive and irritating. Use of public resources to protect private property seldom works and aviation security is proof of it. It is the most un-American of security practices.

  Good security is risk based and encourages people support security efforts. Good security shares information with legitimate users and uses them as a part of the security team.

  Aviation security was developed in fear, following a black swan event. Its basis is bad policy and it has been salted with poor management.

  Comments welcome.
  

• Warren Amyx July 15, 2011 11:48 AM

  Your comments are spot on. It should also be noted that in the world of Healthcare the technoloies for monitoring patients is everchanging whereas in aviation the same standard monitors are utilized in virtually every aircraft.
  I agree with your overall assesment and have felt the same way for some time now.

• Jeff Terry July 15, 2011 1:11 PM

  Thank you for your comments!
  I've often wondered at the parallel of airplane systems safety to healthcare systems safety. Meaning - much of the improvement in aviation from 1960 to 1975 was the result of making planes safer. We clearly need a similar revolution in healthcare. There are many groups working on just this type of thing. But are those just making things more fragmented? How do we align them?
  In any event, I think we should continue to draw lessons and inspiration from other industries. I also think we can't let newcomers underestimate the complexity of healthcare.
  

• Michael Armacost July 15, 2011 9:52 PM

  Harder, perhaps. But I believe most in aviation felt it would be too hard back in the 1970's when there was call to change. There are but a few things if implemented (as intended) would dramatically change the safety profile of healthcare. But my experience has been that the workforce (generalization) does not believe in these changes - lacking a mental model of what it could be...thus the lack or substantial progress since the 2001 IOM. From use of checklist to deliberate practice using simulation - we have only just begun our journey...and like the pilots 40 years ago...this is not going to be easy. Everyone on the team has to be believe that these new (really old) ways of doing work will make a difference - and that the current processes are flawed.

• Bernadette Divine July 16, 2011 7:12 AM

  Comparisons are useful, see "Why Hospitals Should Fly", however they are also limited. Either or polarity, and proving why this won't work here or there, may help some risk mitigation strategies, and or justify a "no change" position.
  A more helpful and healthful approach may lie in looking at assistance companies. These transport patients both ex pat and repatriation clients, in various states of clinical need, across complex, multi-faceted journeys (including air ambulances, inter country transfers, inter disciplinary transfers and through a plurality os systems).
  They unite the flight world with the healthcare world, at cost, within good risk tolerances and with a smile.
  Healthcare does have a lot to learn from the flight world,and the assitance world can translate one world to another.
  Healthcare is not harder, we just lack the systems, processes and acceptance that, because art is not science, it is neither an excuse for continued error, negligence and risk tolerances that would see none of us ever boarding a plane again.

• Alberta Pedroja July 16, 2011 11:40 AM

  Well done, Jeff. Can I add one? The airline industry has pilots, ATC, mechanics, and flight attendants with differing roles and training. A hospital? Doctors, nurses, pharmacists, RRT's, Rad Techs, microbiologists, phlebotomists, etc. all with different language and who are prevented by law from doing what the others do.

• Dr Colin Miller July 16, 2011 5:25 PM

  An interesting blog, which was timed coincidentally with mine based on a real life scenario with a safety aspect of a bomb threat on a plane I was recently on. I took a different angle on the safety issue as you can see at this link:
  http://info.bioclinica.com/blog/bid/60011/What-Happened-Flying-Back-from-the-Osteoarthritis-Imaging-Conference

• Dr Dave Dongelmans July 17, 2011 5:05 AM

  Jeff,

  I totally agree with you. More over the diversity of people working in healthcare is also a big difference. We now need to use/create our own systems to enhance safety. One of the promising roads is using safety managment systems defined in (implemented) protocols. Healthcatre workers are used to protocols and tend to follow these. In our own intensive care unit we are also looking into bundle technology to enhance patient safety.

  Dave Dongelmans

• Robin July 17, 2011 5:10 PM

  Interesting blog. I am both a nurse and pilot and have recently relocated from one state to another which meant flying the plane across the country and beginning a new job in a new state and with a new facility. My take on all this is: As a pilot I do find a human voice at a tower, flight center or other pilot who will always respond if you call on the radio....Most encounters are with utmost courtesy on all parts. As a nurse calling physicians offices or other facilities on behalf of a patient, it is very frustrating to get answers or a human being. One is left leaving messages, paging or frantically trying to get answers to help the patient. Unfortunately, I feel in healthcare few really want to take responsibility. I believe this is in part due to the volume of patients under each office or physicians care.
  Both fields are difficult to manage and wish the best for those helping solve some of our healthcare problems....safety for our patients is so important.

• Jeff Terry July 17, 2011 7:01 PM

  Thank you for your wonderful comments. (And hello, Alberta!)

  I've seen comments on courtesy, security, aviation's safety journey, and several suggesting that patient safety isn't that hard if only people would adopt new attitudes and processes.

  My sense is it's the "people" aspect that makes patient safety so difficult. Delivering care to each patient involves dozens of people over time. Reasons for this include human variation, specialization, regulation and economics. With this complexity even something as simple as staff turnover creates real risk.

  That reminds me of what makes healthcare and aviation so similar. In both cases, the trick is not to fly one safe flight or deliver care well to one patient. The trick is to operate systems of systems that deliver care and move passengers. In healthcare, that means the nuances of our infrastructure, technology, cultures, governance, scheduling and processes must come together to create safe situations every day forever. That's hard.

  In any event, much more to come! I hope one day to blog about how healthcare is safer than aviation. Wouldn't that be exciting?

  Jeff
  

• Dr. Joern Meissner July 18, 2011 4:59 AM

  I am more home in aviation and medical device manufacturing, not in clinical procedures. I agree with your points. Nevertheless, I'd like to add to your list.

  your item 1: not only usability. The key is simplification, standardization of user interfaces and keeping step-by-step procedures intuitive and focused on the important part

  your item 2: "safe" is the wrong concept (assume you mean legally safe, otherwise talking is usually safe), make it mandatory to talk about mishaps, and have a independent body investigate above a certain effect level, and an internal body below that effect level, use this to allow others to learn, not to penalize

  your item 3: most aviation accidents are still caused by poor cockpit communications, especially the Captain not accepting comments by the second in command.

  other significant potential synergies:
  a) alcohol, duty times, pause periods are stricter regulated in aviation, I think. Reduce the physical challenge to nurses and hospital physicians
  b) no single pilot operation for large aircraft.

• Akshay July 21, 2011 10:03 AM

  Simulation is a great tool for healthcare. the problem is communication between stakeholders and simulators. if we can bridge this gap. i am quite sure simulation to predict healthcare operations will be taken more seriously.

• Dr Akash S Rajpal - MD Ekohealth July 27, 2011 9:49 AM

  If healthcare nuances can be compared to another industry, the best example for sure is aviation. A lot can be learned by either industries for 1.large crowd streamlining, 2. use of technology for safety and efficiency, 4. teamwork, 5. & credentialing

• Niall Downey July 29, 2011 5:32 PM

  Hi Jeff, very interesting post. As someone with interests in many of the fields involved here (I have over 20 years experience in healthcare having been a surgeon specialising in Cardio-thoracic surgery; I've also been an airline pilot for the last 12 years flying Airbus A320s round Europe and A330s across the Atlantic and this year having set up Frameworkhealth Ltd to use that experience to teach CRM to the healthcare sector in Ireland in response to the Patient Safety issue), I have been following the comments with great interest. I agree with you that healthcare may be more complex than aviation but must point out, it's the simple things that are killing and maiming patients. Removing the wrong kidney doesn't mean that you are a bad doctor and should've studied harder at college-it means that you are a human being and made a very simple, albeit extremely consequential mistake. The big advances will be made when we can convince healthcare workers that they make mistakes constantly (as do pilots every day)but that with the correct mindset and framework of simple CRM tools (hence the company name!), between 40-80% of them can be trapped and prevented or mitigated.From speaking to doctors at the coalface,we are quite a long way from that point, just as the senior airline captains were back in the 70's and 80s as Michael observed in his comment.Doctors are good at focussing on the high tech,expensive and exciting aspects of their work and work hard at acquiring complex knowledge and skills. Healthcare is complex for sure, but it's the simple stuff that's killing the patients.That's where we need to focus.

• esther carpenter September 14, 2011 3:15 PM

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• James October 28, 2011 9:47 AM

  It's an interesting point you raise certainly but I don't really see the parallels between the two distinctly different areas and safety procedures - patient safety is always going to be more problematic given the nature of the individuals that the healthcare professionals encounter each day. Generally speaking, in order to help improve patient safety, more advanced technologies need to be rolled out across all hospitals such as wireless nurse call systems to help facilitate quick responses to emergencies.

• Niall Downey October 29, 2011 2:26 PM

  Hi James, I'm afraid I have to disagree with you. Both systems involve human beings interacting with complex environments (pilots flying complicated bits of technology in busy airspace with constantly changing parameters in one case; healthcare staff treating complicated human beings in busy hospitals/clinics with constantly changing parameters in the other). The adverse events generally stem from the lower level human factors errors common in both industries. Management needs to resolve issues regarding the environment staff work in (eg.better communication systems as you suggest).This equates to the technological improvements aviation had in the 60's and 70's and needs the bean-counters to be brought along on the patient safety journey to avoid short-sighted decisions which save money in the short term but leave staff exposed to making human factors errors. We also need CRM type training to give the frontline staff the safety net they deserve to avoid human factors errors(as used in aviation from the 80's and to the current day). The adverse events are from a very small percentage of mistakes in an otherwise faultless clinical day-aviation has tools which would be of great benefit to healthcare if given the opportunity.

• Sivaram November 9, 2011 10:29 PM

  Excellent points. I agree that while we can draw a lot of lessons from Aviation, healthcare a much much more complex space with many variables that are in play. First is to acknowledge that we are really not in "Healthcare", but "Illness management". In "healthcare", we need to make the "patient" understand that he is the pilot of his plane, and "maintenance" is done not only the ground, but also while airborne.
  
  When we see that its illness care we are in not healthcare, we would put additional focus on other issues. Then this would be like ensuring that our plane was flight worthy, and repaired between flights. However in a large part of our healthcare practise we focus on symptomatic treatments... would we allow a flight to take off with "duct-tape"-repair?

  I think the lessons we can draw from aviation is great, but I think we in "healthcare" we are forced to stand back and take a broader view, so the differences are missed, as the scale is larger.

  I believe the idea of an empowered investigative team to look into errors and safety failures in healthcare is a must to seriously affect change.

• John Guthrie December 1, 2011 10:50 PM

  I disagree with your premise that these industries differ because of natural complexity is a root cause. The staggering failure rate in healthcare is the direct result of the industry's culture of poor accountability and failure to sustain improvements on any reasonable timeline. Compare these statements to aviation and other safety cultures.
  1) marginal professional retraining, rare ongoing competency testing and turning a blind eye to gross professional incompetency;
  2) continuation of poorly designed work silos, increasing specialization and countless handoffs;
  3) acceptance of highly customized streams of tasks at the patient level vs. standardized workflow using hard checklists;
  4) top heavy system bureaucracies and regulations that often demand little true value in terms of enhanced safety, increased efficiency and transparency.
  5) patients typically in the dark about the real risks of procedures and treatments, and the associated $$ costs for services
  6) over-automation of work that can be achieved more efficiently and safely by simpler means.
  7) the profit motive causing overtesting, duplicative services, and use of technology without evidence of efficacy, safety and economic return to the consumer.

  Your commentary seems intellectually wanting, simply steering to the products you sell.
  
  

• Jerry Kelly February 24, 2012 1:49 PM

  Interesting discussion. Health care affects us all. I happen to be a Captain for a major US airline with 30 years of military and commercial experience. My career spanned nearly the entire metamorphous of how we operate. In fact, as both a military and commercial instructor pilot, I was deeply engaged in implementing these changes in philosophy and attitude. Some background is in order. The aviation community did not come about these changes all by itself. The FAA commissioned a group at the University of Austin Texas lead by R.L. Helmreich to evaluate the human factors affecting safety in the complex and high consequence environment of aviation. This outside group was allowed access to the cockpit to observe. Making a long story short, the human interactions had a tremendous impact on both good and bad outcomes. As touched upon here by others, how healthcare teams interact with one another will be part of the answer going forward. All aspects of team behavior including identifying leaders and appropriately training them along with human factor training for all is necessary. Then healthcare can move on to the concepts of Crew Resource Management and the pinnacle of safety culture known as “Threat and error management”. This is not the end. Also of great importance is standardization. There simply cannot be 10 best ways of doing anything. Medicine would benefit from developing best practices for nearly everything they do, surgeries, admitting, patient handoffs, staff turnovers etc. Not only will errors be easier to identify allowing for corrections, costs would go down with hardware commonality and fewer complications.
  Trying to decide what is more complex, aviation or medicine, (hint-medicine is the answer) completely ignores the fact that there is a problem in healthcare. Some estimates account for 98,000 deaths a year by medical error (that is about two fully loaded 737 aircraft crashing with 100% fatalities every day). It really doesn’t matter if that number is accurate (would 50,000 be acceptable?). That does not even mention patient harms. What is truly of concern is we don’t have anything approaching an accurate accounting. That is where data collection (medical errors) and possible reporting as in a PSO is critical. How does one correct a problem when there is no supporting data? The PSO allows for de-identified data to be used to zero in on errors and what causes them all the while the data will be protected. This does not prohibit peer review or protect medical records themselves. Aviation uses the Aviation Safety Action Program. ASAP actually drives a great deal of commercial aviation training and as importantly, awareness of safety issues.
  A good place to start would likely be “never events”, operating on the wrong person, side/site or wrong procedure. Failure in this area does not reflect on your medical training. It is a failure of the organization to implement human factors techniques including checklists (the most rudimentary of these techniques). Such errors can never be eliminated, but they can be greatly reduced.
  We at Universal Safety Solution, LLC would like to continue this discussion with the goal of showing where the aviation model and healthcare meet.