Future Now
The IFTF Blog
Using Aviation to Guide Patient Safety
There were no commercial airline fatalities in the United States in 2008. In contrast, in-hospital medical errors killed close to 98,000 people, according to a recent study from HealthGrades. What do these two statistics have to do with each other? If Peter Pronovost, a researcher at Johns Hopkins has his way, hospitals, medical device makers, doctors and other stakeholders will borrow from the quality improvement efforts in the aviation world to improve medical care.
In a recent Health Affairs article, Pronovost and his colleagues suggest that hospitals and doctors, in addition to educating doctors about protocol and best practices, develop a system of "strong interventions."
Strong interventions, in effect, reconfigure process and device design to make it virtually impossible to make a mistake. For example, the Health Affairs piece notes that inserting a pulmonary catheter into a patient farther than 60 centimeters "risks puncturing the patient's pulmonary artery," but nothing, other than a doctor's memory, prevents him from inserting the catheter further. Rather than trying to educate doctors--in effect, getting this piece of information to stick in their heads--the Health Affairs paper highlights a couple, more effective options:
A moderate intervention would place a removable bumper on the catheter at 60 cm, prompting a conscious decision by the clinician to exceed normal insertion parameters. A strong intervention would redesign the catheter to make insertion beyond 60 cm impossible. Strong interventions, also called forcing functions, remove any reliance on memory or vigilance and eliminate (or greatly reduce) the potential to make the mistake.
Pronovost gained some fame over the past couple of years, as the subject of a New Yorker profile, which describes another effort to use checklists modeled on aviation checklists to improve patient safety during surgery. The checklists have been credited with saving 1,500 lives in an 18-month pilot study.