At the turn of the century, the Institute of Medicine released a report estimating that up to 100,000 patients a year die of medical errors in the United States. These staggering numbers caught the attention of providers, payers and policy-makers, and resulted in a movement aimed at reducing medical errors. In the quest to make patient-care safer, the healthcare industry has taken inspiration from aviation. The aviation industry has had a great deal of success in improving air travel safety over the course of the last 20 years. Thanks to a number of initiatives, the rate of fatal accidents on domestic airlines in the United States decreased by two thirds between 1987 and 2006.
One of the first initiatives began in 1975 when the Federal Aviation Administration (FAA) developed a system to understand non-catastrophic events -- errors in operation that have the potential to cause harm but do not. An aircraft entering a runway without air traffic control clearance is a non-catastrophic event when there is no harm as a result. Although these non-catastrophic events do not usually yield bad outcomes, they have the potential to become catastrophic. The FAA recognizes that understanding their frequency and cause is important. As such, it has developed a standardized Aviation Safety Reporting System (ASRS) that encourages pilots and air traffic controllers to report non-catastrophic events that would otherwise go unnoticed.
Non-catastrophic events occur frequently in healthcare. The incorrect administration of a medication in patients may be inconsequential on 9 out of 10 occasions. Yet, understanding what led up to this incorrect administration could help avert it, and reduce the chance of a consequential error. In order to understand these events, the healthcare industry has worked to develop a reporting system like the ASRS, which encourages providers to report non-catastrophic events at local and national levels. Currently, there is a push to standardize such reporting systems so that information sharing could occur at a national level.
Another area where the healthcare industry has followed aviation is in the use of checklists. Checklists are used in different stages of flight and are considered mandatory. Failure to use checklists in the aviation industry is considered a violation of protocol. In healthcare, one of the largest initiatives involving checklists is through the World Health Organization’s World Alliance for Patient Safety. This alliance has developed the set of guidelines for safe surgery, which includes a 19-item checklist similar to ones used in aviation. The items on the checklist are divided into 3 sections. The first is a list of tasks that must be performed before the induction of anesthesia, like confirming the identity of the patient, ensuring the correct surgical site is marked and checking the patient’s drug allergies. The second section is a list of tasks that should be performed before making the skin incision. These include anticipating critical events during surgery, ensuring that necessary imaging studies are displayed, once again confirming the name of the patient and reviewing the surgical procedure. Tasks in the final stage of the checklist occur before the patient leaves the operating room and include completion of instrument count and communication of key concerns for patient recovery.
Some of the items on the surgical safety checklist may seem trivial, but the WHO estimates that worldwide, half a million deaths a year would be averted if their checklist were implemented appropriately. A pivotal study published in the New England Journal of Medicine in 2009, examined the effects of implementing the surgical safety checklist at 8 hospitals in 8 different cities across the world. The investigators compared surgical complications and death during the first thirty days post-operatively and found significant reductions in these indicators after the implementation of the checklist.
In addition to the above-mentioned initiatives, other suggested proposals based on aviation that aim to reduce medical errors include:
1) Standardizing the layout of instruments and panels: The aviation industry has come up with a standardized arrangement of keys and panels in the cockpit in order to minimize the chance of error. Experts in the healthcare industry argue that a similar standardized arrangement in the operating room, on resuscitation trays and in computerized systems would reduce errors.
2) Flattening the social hierarchy: Experts in aviation have taken great strides to flatten the social hierarchy, so that individuals feel comfortable questioning their superiors if they notice a mistake. One way the airline industry does this is by using first names only. Some in the healthcare industry have pushed for a similar flattening or restructuring of the hierarchy such that an operating room technician would feel comfortable questioning a surgeon if they notice an error.
3) Prohibiting non-essential communication: During critical times in flight non-essential communication is prohibited to reduce errors. No such rule exists in healthcare but some have been pushing for such a rule, where nurses or doctors in the middle of a critical procedure could wear a colored vest that informs others not to interrupt or communicate about non-pertinent issues.
4) Moving the responsibility for continuing education from the provider to the industry: In aviation, airlines pay for and provide continuing education. In healthcare, physicians have to pay for continuing education out of pocket. Some have argued for a change in this system where the responsibility of continuing education is removed from the physician’s shoulder.
The current steps are a move in the right direction. As various initiatives are implemented to improve patient safety, research in this area should be strengthened and should continue to inform policy-level decisions using data from patient-care and models from other industries like aviation.