QUALITY: Safety Is Not An Accident

Robert Wachter, MD, a respected patient safety expert, has a long but fascinating dissection of the recent US Airways landing in the Hudson River, where everyone survived, versus the worst crash ever, when KLM and Pan Am jets crashed on the runway in Tenerife in 1977 . Safety, we conclude after reading his account of how training, culture and technology have changed in the intervening years, is not an accident. He writes:

What does this have to do with health care? How often do we and our teams drill on management of dangerous situations (code blues, crash C-sections, airway problems, even complex patient transports)? Close to never. How much do we use simulation to practice our responses to these emergencies before they happen? Except for a few early adopters, rarely. How many of us have gone through rigorous teamwork training to learn to better communicate with our "cabin mates" during times of stress? Remarkably few. How often do we need to demonstrate our continued competency in our specialty? For most board certified physicians, about every 10 years (up from "never" 20 years ago). And how well do we learn from our errors? Well, never mind.As we prepare the ticker tape for [US Air] Captain Sully (as we should), we should recall that his success was largely a product of his training and a series of actions taken in commercial aviation—steps that made the Swiss cheese less "holey" and created enough overlapping layers to minimize the chances that an error or safety hazard (in this case, some foolish birds) would lead to tragedy.

...We need to continue to work, as aviation has for the past generation, to train our "pilots" to become Sullys. We in health care are flying over some pretty cold rivers, each and every day.

We've been writing a lot about cost and coverage and the economy recently (for obvious reasons) but it's worth remembering that we aren't just interested in covering people. We want to cover them in a reformed, modernized, streamlined, cost-efficient, high quality, compassionate system. You'd think that would be easier than landing a plane safely in a river, wouldn't you....