Surgical Oncologist and Chairman, Department of Surgery, College of Medicine University of South Florida, USA.
The cascade of interest in patient safety has prompted several experienced healthcare providers to look to other professions for clues as to how to be safe in dangerous situations. The nuclear power industry, the submarine service and commercial aviation all represent “high reliability” systems that have posted enviable safety records. Not surprisingly, hospitals, insurers, patients and doctors have wondered what contributions might be made by these disciplines to patient safety.
Because my own interests in aviation and medicine developed alongside each other, I’ve been especially fascinated by the similarities of and differences between the two professions. Since commercial aviation is demonstrably very safe and healthcare is not, what can we learn from the former to make the latter better? Can aviation safety techniques be lifted from the airlines and deposited in hospitals with minor tweaking and be useful?
Or is such a notion overly simplistic? What is realistic?
There are some fundamental differences between flying airliners and practising medicine. Some are regulatory. In most countries, pilots and airline operations are carefully regulated, inspected and evaluated by federal agencies. In the United States, most regulation of doctors is done by state medical boards, which are quite variable in their approach to regulation. Likewise, pilots work for airlines and if a pilot decides not to follow federal or company policies, he or she is fired. Doctors, on the other hand, are independent contractors in the United States. They are courted by hospitals to bring their patients to those hospitals. In most instances, they have no direct employment relationship with a hospital. Disciplining doctors is often a lengthy (and litigious) process.
Some differences might be called emotional. When a big jet goes down, the headlines reach around the world. Medical error, in contrast, accounts for one death in hospital A, another in hospital B, so that no one doctor or administrator is aware, in such a visceral way, of the enormity of the calamity. Yet, it is estimated that 100,000 patients a year die because of medical errors in the United States alone, the equivalent of several jumbo jet crashes a week. Hard to believe, but true, and likely underestimated. Another difference is the primal motive for the aviator: the pilot is the first to the scene of the accident. In healthcare, only reputations are damaged if a mistake leads to a death or to harm.
Despite these immutable differences, there are several aspects of commercial aviation that lend themselves to medical application; some with effort, some readily. The hard things would involve changes in credentialing and assessment of competency. Simulators, very advanced in aviation and still quite rudimentary in medicine, could be used to assess most clinical competencies. There is a lot of work to be done in this area, but experts reassure me that it can be done.
There are other airline-like things that can be done right now that could have a profound effect on patient safety. We could commit right now to mentoring of new physicians and surgeons, realistic work hours to avoid fatigue related error and emphasis on teamwork and communication.
Teamwork and communication are especially fertile areas for safety advancement. Human factors experts long ago recognised what the ancients knew: to err is human. Teamwork and patterned communication strategies help avoid error, recognise error when it occurs and trap errors before adverse events ensue. JACHO (Joint Commission) analyses of wrong site operations, adverse post operative events and other horrors have consistently found communication to be the most common cause of mistakes. When you consider that mistakes not only take lives, but cause other types of survivable harm (as many as 15 million “incidents of harm,” according to the Institute for Health Care Improvement), training in teamwork and communication seems a reasonably inexpensive and efficacious way to begin to tackle the patient safety problem.
Here are four common, preventable harms occurring in operating rooms that are inflicted on our patients every day:
1. Hypothermia in operative patients: A 2 degree Centigrade difference can account for a three-fold increase in surgical site infection.
2. Glucose control: Moderate hyperglycemia (200mg/dl) at any time during the first post operative day increases the risk of a surgical site infection four fold.
3. Blood transfusion. A gratuitous unit of blood increases the risk of nosocomial infections by a factor of three and increases the chance of cancer recurrence in almost all cancers studied.
4. Fluid administration: Restricted fluid administration during an operation can significantly decrease complication rates
Each of these harms is easily avoidable if there is good communication among anesthesia, nursing and surgical staff. It is a simple matter.
In the four years of its existence, the Surgical Safety Institute has learned a good deal about teamwork and communication training in a variety of different clinical settings. What are the key ingredients for successful application of simple, but very effective, methods in clinical areas where harm and death are common threats to patients and staff?
1. Create clear, cohesive, reliable policies that track the intent of the safety training. If retained, surgical instrument policies hold only nursing responsible, then team training that emphasises the involvement of surgeons, nurses and technicians will not be as powerful. Policies and job descriptions need to have teamwork and communication imbedded in their essence.
2. Hire for teamwork skills: Deal with disruptive team members. Too often disruptive behaviour is tolerated and tolerated again, until a breaking point is reached, when some draconian action is triggered. There must be a code of conduct that applies to everyone on the team. Make teamwork a cultural value held in high regard. This increases efficiencies.
3. Seize any opportunity to begin training. In some institutions a pilot surgeon brings the idea forward. In others a dedicated cath lab supervisor sees the need and urges administration to make plans for training. The call for improvement can come from any point in the organisation. Leaders, both clinical and administrative, succeed when they listen to those “in the trenches.”
4. Emphasise physicians as leaders. Their role in moving training from the hypothetical to reality is essential. “Pushback” from practitioners is reminiscent of airline captain behaviour thirty years ago. Yet even the crustiest pilot learned the value of teamwork when a first officer or flight engineer spotted a problem the captain had overlooked. Data driven, physicians are especially moved by compelling data that support increased safety and efficiencies with teamwork/communication training.
5. Make the training brief, fun, riveting and logical. Teams are expensive. Training needn’t take all day. Sobering data detailing the consequences of error help motivate altruistic care givers; they come away committed to being safer and more efficient. Many teams report improved emotional environments after team training. Equipment, turnover and handoff frustrations largely disappear. One surgeon said, “This has made operating fun again. I’ve got better relationships now with nursing and anaesthesia than ever.”
6. Use tools. White boards, briefing packets, checklists and team observations all make the process intuitive, organised and even fun. Once teams recognise the value of these simple techniques they become enthusiastic; in some cases almost evangelical.
7. Support, support, support. Make sure administrative personnel join the physician leadership in making these simple, easy techniques important institutional values.
Do these things work? In a word, yes. Studies are beginning to appear in peer reviewed literature that show a decrease in wrong site operations, fewer equipment issues, improved efficiencies, decreased nursing turnover and improved nursing and physician satisfaction. Though there are fundamental differences between flying an airliner and operating on the esophagus, simple airline lessons have a lot to offer. That said, and without any disrespect to aviation, it is useful to remember that medicine is more complex, less organised and in many ways, harder. These simple tools can decrease chaos and make it easier.