Wednesday, October 28, 2009

Health Care and Aviation: Zero Tolerance for Sub-Par Performance?

Some aviation-related events and conversations this week prompt this post.
Two pilots have their licenses revoked by the FAA for overflying the Minneapolis airport, being out of radio contact for more than an hour, and lacking situational awareness. No one was hurt. No alcohol or drugs were involved. By all accounts, the pilots are nice people without any previous disciplinary issues. Did the punishment fit the situation, where safety of passengers and flight crew was at risk? Yes. There’s no tolerance for certain behaviors in aviation.

Next week, our survey of disruptive behavior in health care will be published. Many of you contributed powerful anecdotes on the current state of our culture, and how we behave in stressful situations. What would be the response in the health care system to a physician throwing an object at a nurse, or operating on the wrong limb because a time-out wasn’t done? Do we have zero tolerance for certain behaviors in health care, or do we find a way to avoid confronting these dangerous situations?

In a discussion with a national leader of airline pilots last weekend, he pointed out that aviation realized about two decades ago that fatal accidents were occurring that were not equipment or technologic failures, but communication failures. In one incident, people died needlessly because a captain was not receptive to safety concerns of other pilots, flight attendants, or ground crew team members. He cited an example of a pilot who was “checklist driven” instead of listening to the more accurate analysis of his co-pilot and flight engineer regarding the relative risks in the situation they were dealing with. In the end, running out of fuel on approach was the risk that he wasn’t seeing on his checklist. In health care, checklists or “cookbook medicine” are valuable, but equally as important is the judgment and input of everyone on the health care team during the safety-critical events of patient care. We need both to be ultra safe.

My oldest son, a commercial pilot, says that the cockpit crew must verify altitude, airspeed, airport and runway at a certain point before landing. It’s a low risk situation, much like a timeout prior to a procedure, or two-person independent verification of a patient’s ID before administering blood or blood products. If something bad happens during the high risk situation (landing), the pilots can be forgiven if they carried out the pre-landing checklist diligently and seriously. But if they didn’t, there may not be any excuse for an adverse event on landing. In other words, the consequences for the professionals may not be related to the outcome.

Such is the case for the NWA pilots. It seems to me that we often tie the consequences to the outcomes in health care: “Yes, she called the nurse stupid, and threw a needle and syringe at her, but the patient wasn’t affected. We just have to understand that Dr. X is our biggest admitter.”
Finally, in a discussion with physicians at a medical executive committee/health system board retreat recently, one physician commented that it’s hard to see how what happens in the cockpit has any relationship to health care. He thought if a comparison was made to the entire aviation experience – ticketing, baggage handling, dealing with intoxicated, frail, or extremely obese passengers – it would be a better analogy to the variability we deal with in health care. I think that’s correct, but can’t stop thinking about how much better off we’d be in health care if the professionals highest in the hierarchy (physicians) encouraged questions from other professionals, and had zero tolerance for intimidating and threatening behaviors directed toward those lower in the hierarchy.


  1. Mark N. Simon, MD, MMMOctober 28, 2009 at 3:48 PM

    Barry -
    Thanks for your timely and insightful posting. I too was intrigued by the aviation industry's response to this lapse in "situational awareness," and I could only wonder how this would translate to another high-risk industry like medicine. What I find to be most interesting is the zero tolerance nature of the airline industry. By all accounts the two pilots involved here had a clean record prior to this event. Now they no longer have a license to fly. How many times in medicine do we respond to poor behavior with simple warnings or slaps on the wrist? Do we have the courage as a profession to step up and have similar behavioral expectations? At this time, I would say that we do not and that is a disservice to our patients, our colleagues, and ourselves.

  2. I agree with you, Mark. About a year ago, a health care blogger discussed a wrong site knee surgery in which the physician was apologetic, contrite, and upset that it had happened. He'd never had a problem before, and the patient didn't die. The health system leaders said he was a great guy, and had been punished enough by the aftermath. My son said none of that was relevant in aviation - he failed to do a serious and diligent time-out before surgery. A simple behavior in a low risk moment (just prior to surgery) was ignored, and the high risk activity went wrong. Changing our behaviors doesn't require large capital expenditures, but it does require courage, as you say.


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