Patient safety: a plane crash a month

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.