SECOND OPINION:Aviation safety rules could help improve patient care, writes JACKY JONES
HEALTH SERVICES have a poor safety record in comparison to commercial aviation. Only one passenger’s life is lost per 10 million flights, whereas there is one iatrogenic death (brought about by the healer) for every 100-300 hospital admissions.
The World Health Organisation (WHO) estimates that “tens of millions of patients worldwide endure injuries or death each year directly attributed to unsafe medical practice or care”. In Europe generally, an average of one in 10 people admitted to hospital suffers some form of preventable harm.
Aviation safety rules are designed to eliminate the image of hero “rock star” pilots by flattening hierarchies, introducing a “common knowledge” culture in which all staff know what should happen, and systemising safety by standardising everything.
As with pilots in the past, many health service workers have professional cultures which are not good for patient safety, allowing for autonomous decision-making and deferential working environments where junior staff are afraid to challenge their seniors.
The rules that have made flying safer can be applied to health services leading to improved safety for patients and users. Indeed, many aviation safety initiatives have already been successfully transferred to the field of healthcare – checklists, for example. The Surgical Safety Checklist, developed by the WHO, has reduced adverse events by more than a third.
This list identifies the items that must be checked before the anaesthetic is administered, before the skin incision, and before the patient leaves the operating room, including whether the patient has confirmed her/his identity, site, procedure and consent.
This information is so basic that one wonders how any operation ever proceeded without these items being checked, yet we know mistakes happen – such as removing the wrong kidney.
The specialist cancer centres, which have been set up across the State to provide high-volume, multidisciplinary services, are examples of standardising treatment to produce better patient outcomes. Many other services, such as childcare and chronic disease services, are also being standardised. In addition, Irish health services now have robust incident reporting systems.
Another safety rule which could be used in Irish health services – and at no cost – is the “first-names-only” rule, which has been compulsory in aviation since the 1970s.
The theory is that calling flight crew, including the captain, by their first names flattens the hierarchy and fosters a culture where colleagues feel comfortable challenging decisions regardless of rank.
Within the health service, titles and surnames are still routinely used. Funnily enough, health professionals have no problem using the first names of service users, even when patients don’t wish to be addressed in this way.
Another measure which could apply to health services is the “bottle-to-throttle” rule.
Evidence shows that hangovers can affect managerial skills, dexterity and task completion for up to 14 hours after alcohol consumption. So pilots are forbidden to drink any alcohol at all in the eight hours before they fly and must not consume more than five units (2.5 pints of beer) in the 24 hours before they report for duty.
There are strong arguments for also considering explicit restrictions on alcohol consumption by health service workers before they start work.
In aviation, captains and co-pilots alternate between flying and non-flying duties on every journey to promote a non-deferential work environment. In the health service, senior staff usually take the lead role, with more junior staff taking notes or checking results. The “alternation-of-role” rule needs to become mandatory in all health services.
It should be obvious to any intelligent person that flattening hierarchies, standardising diagnosis and treatment, closing unsafe hospitals, and developing fewer, better specialist centres is safer for service users. However, there has been fierce resistance by the Irish public, politicians and health professionals to these service improvements.
Perhaps the reluctance to embrace the changes required to make Irish health services safer is because the consequences are not the same for health professionals as they are as for pilots. Health professionals do not die when something goes wrong for the patient, whereas passengers and flight crew share the same risks.
Jacky Jones is a former regional manager of health promotion with the HSE