Airplane analogies. Last decade, health care was full of them…and here in the first month of the Tens, researchers and quality advocates are wasting no time. We here at New Health Dialogue are just as guilty.
In the fall, Joanne Kenen and I reflected on the 10th anniversary of the Institute of Medicine’s landmark report, To Err Is Human. As hospitalist Bob Wachter reminds us, the number of Americans who die from preventable medical errors is roughly equivalent to a jumbo jet crashing every day. Of course, plane crashes are thankfully rare. There are 30,000 commercial flights per day in the U.S. and the average number of crashes per day is nearly zero. That's not luck. It's because the aviation industry follows rigorous safety guidelines.
With the contemporary patient safety movement entering its second decade, a study conducted in New York and Rhode Island might provide clues for The Tipping Point for transforming all health care environments into cultures of safety.
As reported by
American Medical News, participants in a six-hour training course that covered errors in aviation, related them to medical errors, and discussed how
crew resource management training can prevent such errors were more likely to score highly on “empowerment” metrics. Empowerment in this context means breaking down communication barriers and confronting mistakes and incompetence. And the empowerment persisted for months after those six hours. The study was published in the
Archives of Surgery. (I touched on the importance of speaking up
one year ago, tapping the knowledge of Karl E. Weick and Kathleen M. Sutcliffe’s
Managing the Unexpected and their work studying
high reliability organizations.)
Researchers found that the course, titled “Lessons from the Cockpit,” had another benefit: the two participating hospitals found success when they introduced
perioperative checklists into the OR (modeled on preflight aviation checklists):
Not surprisingly, there was initial resistance because surgeons saw the
checklists as speed bumps that hindered flow. The circulating nurse was then empowered to start the checklist process and the scrub nurse was instructed not to hand up the knife until the checklist was completed. Hospital administration and all clinical chiefs were broadly supportive of this process and any physician who was unwilling to participate was counseled. Use increased over time and many physicians became more supportive when the checklist caught an error, such as antibiotics not given or a specific piece of equipment not being available prior to the start of the case. Consistent checklist use rose from 75% in 2002 to 100% in 2007 and beyond.
Safety-incident reporting doubled from 709 per quarter in 2002 to 1,481 per quarter in 2008. Additionally, it’s important to remember that the researchers did the elusive “easy” things right, too:
The course was multidisciplinary and highly interactive, using videos, team-building exercises, and open forums. To encourage and support attendance, there was no cost to the participant; physicians received Continuing Medical Education credits and a 5% discount on their malpractice premiums, and nurses and ancillary personnel received Certified Nurse Educator units as well as compensatory time. The course was held on a Saturday to avoid work conflicts.
Despite all the evidence, Gawande admits that even he was skeptical that using a checklist in everyday practice would help to save the lives of his patients.
"I didn't expect it," Gawande says with a chuckle. "It's massively improved the kind of results that I'm getting. When we implemented this checklist in eight other hospitals, I started using it because I didn't want to be a hypocrite. But hey, I'm at Harvard, did I need a checklist? No."
Or so he thought.
"I was in that 20 percent. I have not gotten through a week of surgery where the checklist has not caught a problem."
The plane analogy continues: on my list for this spring is
ACHE’s 2009 book of the year,
Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care. Not using checklists are described in that book as “gambling” with a patient’s safety. Checklists say nothing about how to perform bypass surgery -- the surgeon’s years of training dictates that -- but rather it takes care of the routine stuff that is vital to reducing the likelihood of patient harm.
So it appears that the various airplane analogies might in fact guide us to the best way to implement patient safety standards. Time for safety to take off.
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