WHY HOSPITALS SHOULD FLY AND THE NEED FOR
IMPROVING PATIENT SAFETY
“We are guests in our patients’ lives.” -Dr. Donald Berwick
“Safety isn’t expensive, it’s priceless.” -Unknown
A
few months ago, I read an article in the Courier Journal
about a patient that died in a local rehabilitation facility.
His untimely death was a result of a series of preventable
mistakes, including a serious omission of intravenous
antibiotics. I was aghast as I read the article. This hit
too close to home. How could this conceivably happen
in our community with its apparent legacy of excellent
care? When I started looking into this subject more deeply, I
discovered some very alarming statistics. Despite sophisticated
technology, precautions and good intentions, the death rate from
medical errors is estimated to be over 250,000 annually in the
US which makes medical errors the third most common cause
of death behind heart disease and cancer. These numbers are
equivalent to two jumbo jet crashes every day!
When we evaluate the performance of our hospitals, we rely on
safety scores from the national nonprofit organization named The
Leapfrog Group (Leapfrog). Leapfrog provides safety ratings for
more than 2,500 general hospitals in the US assigning A, B, C, D
and F grades to hospitals based on their ability to prevent errors,
injuries and infections. Since 2014 when Leapfrog implemented
this grading system, they have noted improvement in all 15 of their
“process” measures such as hand hygiene and physician staffing in
intensive care units. However, Leapfrog notes that there has been
a lack of progress in outcomes, with hospitals even declining on
certain measures, such as preventing surgical site infections in
patients who have undergone major colon surgery. Many of us
are aware of how some of our local hospitals have received poor
grades with Leapfrog’s patient safety metrics, including the safe
administration of medications, the prevalence of thrombotic
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LOUISVILLE MEDICINE
events, and urinary tract and Clostridium difficile infections.
Aside from the Leapfrog or other similar “health-grade” groups,
there are numerous quality and safety-oriented organizations
such as the Agency for Healthcare Research and Quality (AHRQ),
the Institute for Healthcare Improvement (IHI) and the Patient-
Centered Outcomes Research Institute (PCORI) that include
patient safety and improved patient outcomes in their guiding
principles.
How are we to improve our outcomes and reduce the errors
that are causing over 1,000 deaths daily in our hospitals? One way
is to apply the lessons learned in the aviation industry as a model
for patient safety, as suggested by John Nance in his 2008 book
“Why Hospitals Should Fly-The Ultimate Flight Plan to Patient
Safety and Quality Care.” While this book may seem a bit dated,
the way he parallels the improvements that have been made in
aviation to what needs to be implemented to improve patient
safety are timely today. He describes the sentinel event that led
to cultural change in aviation, the 1977 Tenerife accident. In that
incident, a KLM jumbo jet attempting to take off crashed into a
Pan Am jumbo jet that had not yet cleared the runway, resulting in
583 deaths. It was found after the tragedy that two crew members
had concerns about the attempted takeoff but both acquiesced
to the captain’s wishes to proceed. The changes that occurred in
aviation over the next decade included focusing on the systems
for safety, development of better crew resources, and removing
the powerful hierarchical structure in the cockpit. This particular
change helped mold a totally new culture of safety and teamwork
in which all parties in flight had equal voice. In his book, Mr.
Nance creates a fictional hospital, St. Michael’s, which follows best
practices to create an environment in which all the lessons learned
from aviation are applied to healthcare, changing the culture to