Counterheroism, Common Knowledge, and Ergonomics: Concepts from Aviation That Could Improve Patient Safety

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• In the Literature (131K PDF)

Synopsis

Certain aviation safety measures have been shown to improve safety in health care and save lives. This study identified and classified aviation safety measures not currently used in health care, including the "sterile cockpit rule," which reduces unnecessary distractions during critical activities, and the "first-name-only rule," which promotes a culture where colleagues feel more comfortable questioning one another.

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The Issue

Modern commercial aviation is extremely safe, with only one life lost per 10 million flights. Patients in hospitals do not fare as well: for every 100 to 300 hospital admissions, there is one death caused inadvertently by a health care professional or medical procedure. Aviation’s safety record is not the result of good luck or chance, but is rather the outcome of numerous safety measures in place to protect passengers and crew alike. Many safety concepts adapted from aviation have been successfully implemented in health care at low cost. For example, the World Health Organization Surgical Safety Checklist reduced deaths and surgical complications by more than one-third in some settings. This Commonwealth Fund–supported study, published in Milbank Quarterly, identifies 15 safety practices that are routinely used in aviation but mostly not in health care, and examines their applicability to health care, potential resistance from physicians, and cost benefits.

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Key Findings

• During safety-critical phases of a flight—whether taxiing on the ground or flying at low altitude—pilots and crew must refrain from all nonessential activities, like reading newspapers or engaging in casual conversation. This requirement is known as the "sterile cockpit rule," and its violation has been implicated in many aviation disasters. In health care, such a rule would identify critical junctures—during operations or transitions, for instance—and prohibit distracting activities. Some hospitals, for example, require nurses who are administering medications to wear brightly colored vests, as a signal that they should not be interrupted.
• Up until the 1970s, junior pilots addressed their seniors as "captain," "sir," or "ma'am." But in modern cockpits, a first-name-only rule is employed. Using first names can help flatten the social hierarchy and foster a culture where colleagues feel more comfortable questioning each other, regardless of rank. The same could also be true in health care, if the practice empowered any member of the care team to question a senior member about perceived hazards. 
• In the United States, NASA operates a safety reporting system that offers the incentives of anonymity and immunity to pilots who report an unsafe situation within 10 days. Known as "incentivized no-fault reporting," the practice is already used by some health care systems, like the Veterans Administration. Wider use of the rule within health care reporting, the authors say, could help change the current prevailing culture, in which filing an adverse incident report can be regarded as an act of disloyalty or used as a pretext to punish staff members.
• The authors identified three main types of aviation safety measures: 1) those intended to downplay the role of heroic individuals and instead emphasize the importance of teams and organizations; 2) those that seek to increase and apply group knowledge of safety information and values; and 3) those that promote safety by design.

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Addressing the Problem

Many aviation-based safety measures could usefully be adopted and disseminated more widely throughout health care. However, some may meet resistance from physicians. For instance, enforcing a standardized process may be perceived by doctors as a restriction on their ability to innovate. And measures that expand the circle of people who share professional knowledge may be viewed as undermining to a physician’s status. But over time, this expected resistance is likely to give way to a larger cultural shift, the authors say. In the article, the authors also present an economic framework for examining cost-effectiveness, taking into account compliance and administration costs as well as behavioral changes.

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The Bottom Line

Many aviation safety initiatives not regularly used in health care could have a positive impact on patient safety and outcomes.

Citation

G. H. Lewis, R. Vaithianathan, P. M. Hockey et al., "Counterheroism, Common Knowledge, and Ergonomics: Concepts from Aviation That Could Improve Patient Safety," Milbank Quarterly, March 2011 89(1):4–38.

Keeping the Commitment: A Progress Report on Four Early Leaders in Patient Safety Improvement - The Commonwealth Fund

Authors: Douglas McCarthy, M.B.A., and Sarah Klein
Contact: Douglas McCarthy, M.B.A., Issues Research, Inc., dmccarthy@issuesresearch.com
Editor: Joris Stuyck

Four case studies document the progress achieved in the past five years by health care organizations that were early leaders in patient safety improvement. Their experience reflects an expansion of interventions from individual hospital units to whole facilities and delivery systems, including new settings such as home health care. Approaches include developing practical methods for training, coaching, and motivating staff to engage in patient safety work; designing effective tools and systems to minimize error and maximize learning; and leading change by setting ambitious goals, measuring and holding units accountable for performance, and sharing stories to convey values. Results include advancements in safety practices, reductions in serious events of patient harm, improved organizational safety climate and morale, and declines in malpractice claims. Keeping the commitment to patient safety has required sustained focus on making safety a core organizational value, a willingness to innovate and adapt, and perseverance in pursuing goals.

The four case-study sites are all multicampus, integrated health care delivery systems: Johns Hopkins Medicine (Johns Hopkins) in Maryland; OSF HealthCare, operated by the Sisters of the Third Order of St. Francis, in Illinois and Michigan; Sentara Healthcare in Virginia and North Carolina; and the U.S. Department of Veterans Affairs (VA), which operates facilities nationwide.

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• Case Study Overview Report (919K PDF)

Related

• Publications
  • Advancing Patient Safety in the U.S. Department of Veterans Affairs
  • Sentara Healthcare: Making Patient Safety an Enduring Organizational Value
  • OSF HealthCare: Promoting Patient Safety Through Education and Staff Engagement
  • Johns Hopkins Medicine: Embedding Patient Safety in a University-Affiliated Integrated Health Care Delivery System

Agency Information Collection Activities: Proposed Data Collection; Comment Request

SUMMARY: This notice announces the intention of the Agency for Healthcare Research and Quality (AHRQ) to request that the Office of  Management and Budget (OMB) approve the proposed information collection  project: ``Pilot Test of the Proposed Pharmacy Survey on Patient Safety Culture.'' In accordance with the Paperwork Reduction Act, 44 U.S.C.3501-3521, A1-IRQ invites the public to comment on this proposed information collection.

DATES: Comments on this notice must be received by May 10, 2011.

ADDRESSES: Written comments should be submitted to: 

Doris Lefkowitz, Reports Clearance Officer, AHRQ, by e-mail at 
doris.lefkowitz@AHRQ.hhs.gov.

    Copies of the proposed collection plans, data collection 
instruments, and specific details on the estimated burden can be 
obtained from the AHRQ Reports Clearance Officer.

FOR FURTHER INFORMATION CONTACT: 

Doris Lefkowitz, AHRQ Reports 
Clearance Officer, (301) 427-1477, or by e-mail at

 doris.lefkowitz@AHRQ.hhs.gov.

SUPPLEMENTARY INFORMATION:

Proposed Project

Pilot Test of the Proposed Pharmacy Survey on Patient 
Safety Culture

    As the baby boomer population ages, the general U.S. population 
continues to grow, and as drug therapies for the treatment of chronic 
diseases become more efficacious, the expected increase in the number 
of prescriptions and demand for pharmaceutical products is likely to 
increase the potential for medication errors in community/retail 
pharmacies. In 2007, there were about 56,000 community/retail 
pharmacies, including about 22,000 traditional chain pharmacy 
companies, nearly 17,000 independent drug stores, about 9,300 
supermarket pharmacies, and about 7,700 mass merchant pharmacies. 
Numerous reports substantiate the presence of medication errors in 
pharmacies. For example, one national observational study of 
prescription dispensing accuracy and safety in 50 pharmacies in the 
U.S. found a rate of about 4 errors per day in a pharmacy filling 250 
prescriptions daily. This error rate translates to an estimated 51.5 
million errors occurring during the filling of 3 billion prescriptions 
each year.

    Given the widespread impact of pharmacies on patient safety, the 
new Pharmacy Survey on Patient Safety Culture (Pharmacy SOPS) will 
measure pharmacy staff perceptions about what is important in their 
organization and what attitudes and behaviors related to patient safety 
are supported, rewarded, and expected. The survey will help community/
retail pharmacies to identify and discuss strengths and weaknesses of 
patient safety culture within their individual pharmacies. They can 
then use that knowledge to develop appropriate action plans to improve 
their practices and their culture of patient safety. This survey is 
designed for use in community/retail pharmacies, which includes chain 
drugstores (e.g., Walgreens and CVS), supermarket pharmacies, 
independently owned pharmacies, and mass merchant pharmacies (e.g., 
Wal-Mart, Costco, Target), not for use in hospital pharmacies.

    This research has the following goals:
    (1) Cognitively test and modify as necessary the Pharmacy Survey              on Patient Safety Culture Questionnaire;
    (2) Pretest and modify the questionnaire as necessary;
    (3) Make the final questionnaire available to the public.

    This study is being conducted by AHRQ through its contractor, 
Westat, pursuant to AHRQ's statutory authority to conduct and support 
research on healthcare and on systems for the delivery of such care, 
including activities with respect to the quality, effectiveness, 
efficiency, appropriateness and value of healthcare services and with 
respect to quality measurement and improvement. 42 U.S.C. 299a(a)(1) 
and (2).

Full Federal Register Announcement

Better OR Teamwork Cuts Mortality Rates

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Joint Replacement Registry Improves Quality of Care from MedPage Today

By Nancy Walsh, Staff Writer, MedPage Today

A total joint replacement registry begun in California in 2001 has enhanced patient safety and quality of care by tracking implant performance and outcomes, according to a new report.

For instance, registry data have shown that the cumulative five-year survival of both primary total hip and knee replacements currently is 97.3%, reported Elizabeth W. Paxton, MD, from Kaiser Permanente in San Diego, and colleagues.

Analysis of data from the registry also has determined that the main reasons for hip revisions are instability and infections, the researchers wrote online in Clinical Orthopedics and Related Research.
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Transparency and Public Reporting Are Essential for a Safe Health Care System

What will it take to motivate hospitals to do what we know works to make health care safer? Of the three major approaches to improving patient safety—regulation/accreditation, financial incentives, and public reporting—the most promising is public reporting of performance information and feedback to providers. Transparency is an idea whose time has come and both hospitals and the public will be better off because of it.

Read/Download Issue Brief

Senior Citizens Do Best in Specialized Orthopedic Surgical Care: Medicare Study

The more specialized a hospital is in orthopedic surgical care, the better the outcomes appear to be for senior citizen patients undergoing hip and knee replacement surgery, University of Iowa researchers report in a new study of Medicare patients.

Among more specialized hospitals, there were fewer serious post-surgical complications such as blood clots, infections and heart problems, as well as fewer deaths.

The findings, which were published online Feb. 11 by the British Medical Journal, were based on data for nearly 1.3 million patients who received hip or knee replacement surgeries between 2001 and 2005 at 3,818 hospitals in the United States.
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• Medicare data reveals differences in orthopedic surgical outcomes (scienceblog.com)

Patient safety surveillance: keeping watch in hospitals, from sinks to surgery

Maryland gets federal stimulus funds for "secret shoppers" to monitor health professionals' hand hygiene. A Rhode Island hospital will videotape surgeries. Some worry about Big Brother.

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Healthcare-Associated Infection: Not on My Watch - Kimberly-Clark Health Care

When someone develops an infection at a hospital or other patient care facility that they did not have prior to treatment, this is referred to as a healthcare-associated (sometimes hospital-acquired) infection (HAI).

Healthcare-associated infections (HAIs) are a global crisis affecting both patients and healthcare workers.

According to the World Health Organization (WHO), at any point in time, 1.4 million people worldwide suffer from infections acquired in hospitals.

A Centers for Disease Control (CDC) report published in March-April 2007 estimated the number of U.S. deaths from healthcare asociated infections in 2002 at 98,987.

The risk of acquiring healthcare-associated infections in developing countries is 2-20 times higher than in developed countries.

Afflicting thousands of patients every year, HAI often leads to lengthening hospitalization, increasing the likelihood of readmission, and adding sizably to the cost of care per patient.
Read More

Hospital Workers May Trigger Dangerous Outbreaks - Forbes.com

(HealthDay News) -- Hospital workers who see many patients may play a disproportionate role in spreading dangerous hospital-acquired infections, a new study finds.
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Safety Gurus: Penalize Doctors Who Don’t Follow the Rules - Health Blog - WSJ

By Laura Landro

Should hospitals start penalizing doctors and nurses who fail to follow patient safety rules?

That’s one solution proposed by Peter Pronovost of Johns Hopkins and Robert Wachter of the University of California at San Francisco. Writing in the New England Journal of Medicine, the doctors contend that the failure to hold clinicians accountable for patient safety is the main reason health care is still riddled with errors, adverse events, and just plain non-adherence to some of the most basic rules.
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• Surgical Deaths Linked to Handling of Complications (nlm.nih.gov)
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AMNews: Oct. 1, 2009, 2009. HHS will fund $25 million in tort reform projects ... American Medical News

The White House quickly followed up on President Obama's pledge to authorize medical liability demonstration projects, announcing Sept. 17 the availability of $25 million in grants to be doled out to states by the Dept. of Health and Human Services.

Grants for up to three years and $3 million each will be awarded on a competitive basis to states and health care systems to test models that improve health care quality and patient safety while decreasing medical liability pressures on doctors.

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The Health Care Blog: Another Look: Incident Reporting Systems

by BOB WACHTER

When the patient safety field began a decade ago with the publication of the IOM report on medical errors, one of its first thrusts was to import lessons from “safer” industries, particularly aviation. Most of these lessons – a focus on bad systems more than bad people, the importance of teamwork, the use of checklists, the value of simulation training – have served us well.

But one lesson from aviation has proved to be wrong, and we are continuing to suffer from this medical error. It was an unquestioning embrace of using incident reporting (IR) systems to learn about mistakes and near misses.
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Common Formats for Patient Safety Data Collection and Event Reporting

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The Patient Safety Act (at 42 U.S.C. 299b–23) authorizes the collection of this information in a standardized manner, as explained in the related Patient Safety and Quality Improvement Final Rule, 42 CFR part 3(Patient Safety Rule), published in the Federal Register on November 21, 2008: 73 FR 70731–70814. As authorized by the Secretary of HHS, AHRQ coordinates the development of a set of common definitions and reporting formats (Common Formats) that allow healthcare providers to voluntarily collect and submit standardized information regarding patient safety events. The initial release of the formats,Version 0.1 Beta, was announced in thevFederal Register on August 29, 2008: 73 FR 50974–50976. The purpose of this notice is to announce the availability of the expanded and enhanced Common Formats Version 1.0 and the process for their continued development and refinement.

DATES: Ongoing public input.

ADDRESSES: The Common Formats can be accessed electronically at the following HHS Web site: http://www.pso.ahrq.gov/index.html.

FOR FURTHER INFORMATION CONTACT:
Susan Grinder, Center for Quality Improvement and Patient Safety, AHRQ,
540 Gaither Road, Rockville, MD 20850;
Telephone (toll free): (866) 403–3697;
Telephone (local): (301) 427–1111; TTY
(toll free): (866) 438–7231; TTY (local):
(301) 427–1130;
E-mail: pso@ahrq.hhs.gov.
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AHRQ Hospital Survey on Patient Safety Culture

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Request for comment on the collection of information for Agency for Healthcare Research and Quality’s(AHRQ) Hospital Survey on Patient Safety Culture Comparative Database.
Read Morfe

How to Retain Nursing Home Staff and Improve Organizational Performance - The Commonwealth Fund

Based on the experiences of more than 400 nursing homes, the Staff Stability Toolkit is designed to serve as an evidence-based resource for nursing homes that are working to reduce staff turnover. The toolkit, developed by Quality Partners' of Rhode Island with Commonwealth Fund support, identifies some of the perverse incentives, such as giving hiring bonuses rather than retention bonuses, and poor management practices, such as ineffective hiring and scheduling, that contribute to high staff turnover in nursing homes. It also offers guidance on ways to sustain employee stability. Read More

Pitching Patient Safety and Hospital Transparency on YouTube - Health Blog - WSJ

By Laura Landro After a medical error, hospitals’ traditional approach has been to retreat behind a wall of silence, on the advice of risk managers and attorneys. But some hospitals are taking a different approach, fully disclosing medical errors, apologizing and offering financial compensation up front – and inviting patients and families to participate in patient safety improvement efforts. Read More

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The Health Care Blog: Interview: Bob Wachter on reform, safety, primary care and everything

One of the best commentators around on the issues of patient safety, health care quality and basically everything to do with health care organizations is UCSF Professor Bob Wachter. Bob has been in the trenches as one of the leaders in the hospitalist movement, a major driver behind improving patient safety, and has also straddled the worlds of medical practice as a PCP, academia at UCSF, and been publicizing this all to a wider audience--particularly with his 2005 book Internal Bleeding and his more recent book Understanding Patient Safety. Then of course there are his occasional blog posts both on Wachter's World and here on THCB. This was a really fun conversation and somehow Bob remains an optimist.Here's the interview