This is an excerpt of the paper “Rethinking Use Of Air-Safety Principles To Reduce Fatal Hospital Errors”, with the title above, highlighting the message in question.
Health Affairs
Andy Pasztor, Adam Andersen
AUGUST 26, 2022
Executive Summary by:
Joaquim Cardoso MSc.
transform health — institute for continuous transformation
patient safety unit
August 26, 2022
Three Strategies To Improve Safety
Experts point to health care’s failures to fully incorporate three fundamental strategies relied on by airlines and their federal regulators:
- 1.extensive voluntary reporting of serious incidents;
- 2.prompt and widespread dissemination of information about life-threatening hazards; and
- 3.user-friendly equipment designs intended to prevent a repeat of the same fatal errors.
Systemic lapses in hospital safety were highlighted by the Institute of Medicine’s seminal 1999 report, “To Err is Human,” which sparked the modern patient safety movement.
Over the next two decades, Atul Gawande’s internationally acclaimed book, The Checklist Manifesto, and follow-on publications popularized a bevy of aviation-derived safeguards.
But health care needs to move beyond those early steps.
Undue emphasis on medical checklists, mimicking an aviation procedure initially developed many decades ago, frequently impedes reliance on newer and more effective safety techniques.
Undue emphasis on medical checklists, mimicking an aviation procedure initially developed many decades ago, frequently impedes reliance on newer and more effective safety techniques.
Checklists’ usefulness in medicine has been oversold, according to Raj Ratwani, director of MedStar Health’s National Center for Human Factors in Healthcare.
After initially embracing them above other safety practices, physicians and hospital administrators have opted for more sophisticated safety tools, including robust data sharing, enhanced teamwork, and greater responsibilities for junior staff.
Checklists’ usefulness in medicine has been oversold, …
After initially embracing them above other safety practices, physicians and hospital administrators have opted for more sophisticated safety tools, including robust data sharing, enhanced teamwork, and greater responsibilities for junior staff.
2.Data Sharing
Medicine already has hundreds of national and state registries collecting data on patient outcomes, complications, and best practices.
They are all confidential and shielded from legal discovery.
In theory, the model is similar to air-safety reporting.
Yet, unlike aviation, there is no comprehensive database aimed at preventing hospital errors.
Information often is contained in digital silos that communicate poorly, if at all, with each other.
Typically, incident data are used by the government to financially punish hospitals for safety lapses — but only after problems occur.
That discourages timely public disclosure of errors, which translates into limited opportunities for ambitious data mining to uncover precursors, root causes, and essential takeaways.
Generally lacking are urgent recommendations that, in turn, can be quickly adopted by other health care providers.
Instead, medical feedback loops primarily focus on reporting the incidence of adverse events.
Without more thorough voluntary reporting and deeper data analyses, experts say hospitals are likely to find it difficult to implement effective and sustainable safety programs.
Without more thorough voluntary reporting and deeper data analyses, experts say hospitals are likely to find it difficult to implement effective and sustainable safety programs.
Names mentioned
To Err is Human — Building a Safer Health System
Institute of Medicine (US) Committee on Quality of Health Care in America; Editors: Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson.
Raj Ratwani, director of MedStar Health’s National Center for Human Factors in Healthcare.
Atul Gawande’s internationally acclaimed book, The Checklist Manifesto,
Christopher Hart, a former chairman of the NTSB
Kathleen Bartholomew, a former nurse and hospital manager
David Mayer, head of the safety research arm of Maryland-based MedStar Health
Christopher Hart, a former chairman of the NTSB
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