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.
3.User-Friendly Medical Devices And Technology
Moreover, health care hasn’t followed aviation’s lead incorporating human-centered technology.
Modern jetliner cockpits are designed — and then evaluated before and after planes enter service — to ensure the automation they rely on is user friendly.
So far, that principle isn’t ubiquitous in operating rooms or other clinical settings.
“What I don’t see are human-factors experts” who are “designing the equipment but also designing the processes” to avoid human mistakes, says Hart, a board member of the Joint Commission that accredits hospitals.
“What I don’t see are human-factors experts” who are “designing the equipment but also designing the processes” to avoid human mistakes …
More user-friendly medical equipment, combined with advanced electronic health records and predictive analytics, could yield dramatic safety improvements for patients.
Potential benefits could resemble the way highly integrated cockpits and in-depth data analyses have revved up airline safety since the late 1990s.
At this point, most hospitals rely on software designed to prevent mistakenly giving excessive doses of drugs to infants or providing adult patients with medications that should never be taken together.
Another safety push entails installing common designs of switches and control knobs on different brands of equipment, including defibrillators and infusion pumps, to prevent staff confusion that can lead to serious mistakes.
For their part, aircraft makers and equipment suppliers want to harness artificial intelligence to pinpoint emerging dangers.
Proposed safeguards, for instance, include systems able to autonomously pinpoint airports, perform essential radio communications, and actually land aircraft and then safely stop them on runways if pilot actions suggest confusion or incapacitation.
Without any human intervention, cockpits of the future also likely will carry out emergency maneuvers to prevent deadly stalls and avoid collisions with other aircraft, mountains, or even man-made obstructions.
Without any human intervention, cockpits of the future also likely will carry out emergency maneuvers to prevent deadly stalls and avoid collisions with other aircraft, mountains, or even man-made obstructions.
Eric Horvitz, Microsoft’s chief scientific officer, says that path could unlock “the sleeping giant of health care” innovation.
Tech companies and hospitals have already rolled out solutions to help identify patients most likely to deteriorate or suffer complications.
Artificial intelligence (AI) champions also point to existing aviation technology that allows some pilots, immediately after completing a flight, to review a digital and video replay of their performance and compare it to those of other pilots.
Similarly, certain robot-assisted surgical systems use algorithms based on previous procedures to help surgeons move the controls more smoothly.
And more hospitals are tapping into AI networks to identify emergency department or intensive-care patients at highest risk for strokes or other life-threatening conditions.
But here, too, medicine appears to be significantly trailing aviation.
Aircraft manufacturers already have devised cockpit features that anticipate pilot reactions and can unilaterally take over flight-control systems in dire situations.
Physicians, however, continue to resist ceding decision making or control of patient procedures to computer networks — no matter how advanced they may be.
Aircraft manufacturers already have devised cockpit features that anticipate pilot reactions and can unilaterally take over flight-control systems in dire situations.
Physicians, however, continue to resist ceding decision making or control of patient procedures to computer networks — no matter how advanced they may be.
Further complicating matters is that while AI-enabled software and devices are pitched as time-saving, cost-cutting, and more accurate solutions to complex medical procedures, …
… the Food and Drug Administration is playing catch-up policing fledgling initiatives fraught with technical and ethical questions.
Conclusion:
Unless the medical community re-envisions how reliable, time-tested aviation principles can boost hospital safety, the status quo portends many more years of well-meaning discussions. What’s likely to remain missing, however, are essential changes to reduce the tragedy of deadly patient errors.
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
Originally published at: https://www.healthaffairs.org
