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WHEN a plane crashes and lives are lost, the media reports the details, and interviews family members as well as aviation specialists, often over many weeks. Detailed investigations, examining human as well as systems errors, often take weeks to months and are reported in detail.
More often than not, significant changes to training or systems are made to prevent such an event from happening again. Changes include systems such as checklists, communication, fatigue management and training, especially focused on cultural changes. Tools such as “crew resource management” training focusing on human factors are now mandatory for all staff of many commercial airlines. This has led to commercial flights beingone of the safest ways to travel, with only 0.01 deaths per 100 000 people, compared with 4 deaths per 100 000 people for car travel.
In comparison, it is estimated that more than 400 000 patients die of preventable errors in the US and there are 750 deaths per month in the UK that could have been avoided. In Australia it is estimated that more than 33 000 patients die per year from avoidable causes, and it is estimated that more than 12 000 of those could have been stopped by better treatment.
Translating these numbers into aviation language, there is a Boeing 747 crashing each month in Australia alone. Yet these numbers have increased over the past 15 years (reported to be 100 000 avoidable deaths in the US in 1999) in spite of changes such as reporting, data collection, safety and quality indicators, safety accreditation and standardised care.
Many clinicians reject the comparison of health with aviation. Medicine is still seen by many as an “art”, relying on the knowledge, skills and competence of an individual. And this is often reflected in the system of patient care – the historical model of care where patients in hospitals are admitted under the care of a specific consultant, with a perceived tight ownership of the patient and decision-making by the treating consultant.
Yet poor communication, lack of clarity, deficiencies of forcing functions, poor access to information, poor team functioning and lack of adherence to safety standards now make hospital errors the third leading cause of death in the USA, after cancer and heart disease.
Poor communication, a common occurrence in health care, remains a leading cause of medical errors and patient harm. A review of reports shows that communication failures were implicated at the root of over 70% of sentinel events. Health care workers today also acknowledge that poor communication is perhaps one of the most prevalent problems in medicine. Poor communication is likely to evolve out of the inevitable and irreversible hierarchy of power within hospitals.
While it is true that the clinicians aren’t at risk of dying when a patient dies, unlike a pilot in a crashing plane, many daily activities in a hospital are as common and standard as a commercial flight. Yet the main changes in aviation which have been related to improved safety have been in communication.
What can health professionals do to achieve a similar success and reduce the number of patients dying unnecessarily or being harmed?
The most important step is to address culture and hierarchy. Adherence to policies, safety procedures, communication training, teaching and use of techniques to escalate concerns, clear descriptions of expectations, definitions of job boundaries, and reporting of adverse events are difficult to monitor and improve in complex organisations such as health facilities and are not as tightly regulated as in aviation.
While hierarchy is important, addressing a culture of a “hidden curriculum”, engaging clinicians, making data on patient harm visible, transforming behaviours and changing health care from a volume-based to a value-centric system, will improve patient safety and increase staff engagement and satisfaction.
Those health services that have improved safety and quality of patient care have significantly changed administrative processes, to ensure that the governing structure is supportive of health professionals, and they have increased clinician participation in management decisions to ensure stable growth and ultimately better patient outcomes, satisfaction and loyalty.
While hierarchy is a necessary part of most organisations, health care practitioners and administrators need to rapidly reassess their own management structures to determine whether or not they have truly shifted their organisations far enough to embrace a more collaborative, innovative and engaged workforce.
If the aviation industry can do it, why can’t we? Or does it take the equivalent of a Boeing 747 crash per month for people to notice?
Dr Zsuzsoka Kecskes is a neonatologist at Canberra Hospital, and Associate Dean at the Australian National University Medical School, teaching quality and safety. She is a staunch advocate for quality and safety in health care, and patient-centred care. She is a member of the MJA Editorial Advisory Committee.
While aviation and medicine are distinctly different their strife for safety puts our medical laissez-faire approach to shame and contrary to Dr Hargrave’s comments an airline pilot is certainly not the only or even the main driver in aviation safety and neither the one pocketing the 1000$ per passenger that are needed to keep the whole team working and a company making profits. Most pilots by the way earn less than Australian specialists billing privately on top of medicare, earning between 150 and 300K depending on airline, aircraft and seniority.
The shooting of a doctor as per the NEJM article is typical for America where even doctors performing medically indicated legal abortions are regularly targeted by killers – it is hardly an argument against requesting more safety and controls in medicine, rather to the contrary.
Once you have a close relative or dear patient or a personal experience going through the trials and tribulations of a poorly run specialist review/treatment/admission due to fatigue/poor communication/cutting corners with bad outcome you might come to a differing view on what kind of safeguards would be appropriate for the delivery of high quality care.
Dr Bikshandi has a valid point, that making an inappropriate analogy between 2 different industries, aviation and medicine, helps to create unrealistic expectations.
A Qantas 747 captain is not allowed to fly a 767, because he is certified to fly a single type of aircraft. Extrapolating to medicine would see the demise of all general practitioners and general RMOs. A knee surgeon would not be able to operate on a hip, nor a cranial neurosurgeon on a spine. The specialist resuscitation team would be fully prepared and instantly available at every consultation or procedure, just as the airport fire crew is at every takeoff and every landing.
A Qantas 747 captain is not allowed to fly alone, but must always have at least 2 other qualified pilots in the room at all times. Every professor will need 2 other professors with her at all times who all confirm every decision.
Every doctor’s action, and every change of management, even by these 3 experts, would be remotely monitored in real time by medicine traffic controllers, who would check for incompatibilities like drug interactions. There would be instant warnings to every doctor whose course of management was risky. In the event of a complication, the consulting room voice recorder would have all the information needed for a root cause analysis.
Then again, a 747 on its way to London has 300 passengers each paying at least $1000 co-payment for the trip. I suspect that for $300,000 per consulting day, with as little as $1000 co-payment per patient, we could indeed make medicine as safe as aviation.
William has pointed out the stark contrast between the numbers in the UK and Ausgralia. I am always very daubtfull and critical about statistics particularlay if they compare different health systems. It is often a comparism of apples and pears.
However having worked in the Uk before coming to Australia, I must say that safe working hours are much stricter enforced in the UK than in Australia. It would be very nice if the authors could go back and check if the statistics from the UK and Australia are really comperable, because if they are, then we have a really huge problem.
If that is so, then safe working hours will be major contributing factor.
Seriously flawed analogy Aviation and Medicine. I request the readers to read this: http://www.nejm.org/doi/full/10.1056/NEJMp1501253?af=R&rss=currentIssue
After a surgeon was shot dead by a patient’s relative, the above was published. I am surprised we are still using the aviation analogy! I request the editor of mja to contact the author regarding her opinion on the above shocking incident borne out of unnatural expectations created by incongruous comparisons.
The article does not comment on a “no-blame culture” which has contributed to aviation safety by removing a reason to hide problems, and as a result, has helped to make problems more discoverable.
Whilst administrators and health departments mouth “no-blame” and “it’s the system not the individual”, blame is embedded in the system. Incident reporting systems which are supposed to promote quality improvement have been used as de facto complaint systems, and as result, their original purpose has been undermined.
In contrast to the 30 and 40 year clinicians, I have seen many systemic errors in my time which were completely avoidable and which have resulted in injury or death. Occasionally, there has been an investigation performed by inexperienced and untrained individuals with no lasting system wide improvement that might prevent future incidents. Compare this with the detailed and thorough investigations that occur in aviation that not only identify what happened but also why and what can be done to prevent future incidents – these are often very simple solutions. Medicine is not aviation but we can learn from the aviation example.
For ‘preventible deaths’ don’t we often mean deaths for which an explanation is found? I find it fascinating that with doctors spending fewer and fewer hours in postgraduate hospital training, there has been a concomitant increase in these ‘preventible deaths’ (an apparent four-fold increase in two decades). Tomorrows doctors are in my view only half as well trained as yesterdays, both clinically and as communicators because they have absolutely no continuity of responsibility for decisions they make in the few hours they are at work. They all receive a terrible responsibility shock when they leave the sheltered employment of a hospital and find themselves accountable to themselves and their patients, and not a bunch of half-whitted administrators. In this respect the comparison with the airline industry is, in my view, quite illogical and misleading.
Where is the evidence that these so-called avoidable deaths are as a result of “fatigue” and not simply poor knowlege and inadequate training? At least the hierarchical system produced doctors who understood and accepted responsibility for their decisions, an attribute I seldom see in our current crop of 9-5 hospital doctors.
I think that deaths due to medical errors represent a spectrum. The contribution to patient deaths from medical error is not simply either 0% or 100% but generally something in between. The error basically increases the patient’s risk of dying, admittedly sometimes to 100%. In this sense some errors will be more significant than others. I am not sure that the modelling fully captures this.
Also the outcome of death itself will be more impactful in some cases than in others. For example, the death of a newborn will have more impact in terms of quality adjusted life years lost than a death in a nursing home. I think that quality adjusted life years lost would be a better measure to use in modelling where medical error ranks among the leading causes of death.
What mechanisms do we currently have in place to help our doctors keep in top physical and psychological condition?
There exist mindfulness progams that can improve thinking styles to create space for the working brain to be used maximally as a problem solving tool. Instead brains are placed in a continuous defence mode – may become a character trait that may then cause pyschosocial fallout .
Perhaps our HR departments need an intensive goal shift, becoming staffed by higher quality, authenitic, intelligent beings whose chief aim should be to keep hospital doctors in better condition, rather than to exploit them. Politically driven cunning needs to be replaced with a more compassionate educational and guiding style of management.
In their later years, many doctors then become susceptible to charlatans employed by companies who use subtle yet ruthless means. Some take notes on doctors’ personal information and record their attitudes to absolutely everything, proceeding to formulate ways to maximise their company returns (using doctor’s dedicaton to their own advantage)
A more holistic approach to caring for our doctors, needs to be in place from the moment they are selected to be trained as doctors, through to their retirement.
There’s a related article in April 2012, Journal of Patient Safety.
An NTSB for Healthcare, Learning from Innovation: Debate and Innovate or Capitulate.
http://www.safetyleaders.org/NTSBforHealthcare/home.jsp http://journals.lww.com/journalpatientsafety/Abstract/2012/03000/An_NTSB_for_Health_Care___Learning_From.2.aspx
Couldn’t agree more with the author. I do question though the disparity in deaths between the UK and OZ. I suspect that our systems here are probably a bit better at picking up the ‘unecessary deaths’, althoughh it may in part also be a matter of not comparing like with like.
Of course, to improve this all costs time and money, which is usually the sticking point when it comes to implementation…
Long working hours are a continuing problem in medicine.
I have two medical sons, both around 6 years post graduation. Both work in large public hospitals. One is in ICU and works 7 days on ( 12 hours days.. really 14 hours after handovers ) then 7 days off ( Followed by 7 nights on ( 12hr shifts. ). My second son is trying to get into surgical training and works at least 60 hrs per week, a large proportion of which is unpaid and unrecognized.
Both are consistenly tired and their social lives are virtually non existent.
Having experienced similar hours when I trained for my own specialty, I think that despite all the talk, expected working hours have not improved over 30 years. With all the talk of bullying in the medical workforce, I feel that much of the onus lies on medical beaurocracy, which insists on such long hours of unpaid overtime, and continues to pretend that these circumstances have been eradicated.
Anonymous
Could not agree more with the tone of your article.
The aviation analogy is increasingly being rejected within health circles. Clinicians cite the complexity of the system, the continuous nature of our work, the variable teams and the illness of the patients as reasons for why we should not be “treated like pilots”.
I think this is missing the point. We need to acknowledge that while there are many factors in healthcare that are different, there are also many that are similar, and that we can learn much from their approach to safety and quality improvement.
The introduction of more stringent training, the use of checklists and other memory cues (particularly in crisis), crew resource management principles, documentation of process and prowess and many other examples has led to commercial aviation becoming an incredibly safe industry.
The holes in our coal-face governance processes are wide. Appropriate training for the use of equipment, documented competence for procedural skills, orientation to workplace and communication of critical information to staff members are just a few of the glaring oversights our industry faces. And in contrast to other comments, I see this occuring on a daily basis.
Its time for our industry to take a stand and deal with these issues head on.
hospital errors causing mortality have been discussed for a very long time and are clearly a problem. however, it is difficult to believe that the UK with a population of 64 million has a death rate from hospital errors of 750 per month or 9000 per year, while Australia, with a population of 24 million, has a death rate of 2750 per month, or 33000 per year.Are our hospitals really about 2.5 times more error prone than UK hospitals? Such statistics are very questionable!
Congratulations! For being so open about the system training and culture. Absolutely right in all respect.
Passengers on airplanes are not sick. People in hospital are there because they are…..and sometimes they die. Modern medicine has achieved such success that we now have a vast number of people living to over 100 and nursing homes stuffed to the brim with the elderly requiring full time treatment. I have been in the hospital system for 30years now and I do not see frequent dreadful mistakes that lead to deaths or morbidity. I do see that sometimes the disease wins and I see a lot of money wasted on over treatment and investigation because the population is now so paranoid about disease and “wellness”.