To prevent errors, hospitals could learn from other industries
LETTERS
I read your article about medical errors in healthcare institutions, and I thought it was very well done [" 'It's Never Just One Thing' That Leads to Serious Harm," Jan. 28]. This is a topic that has been an interest of mine for a while.
We have seen this phenomenon before, in the aviation industry. After a series of catastrophic crashes in the 1970s, the Federal Aviation Administration asked the NASA Ames Research Center to examine some of the "human factors" that led to seemingly trivial errors with devastating consequences.
They developed the principles of what has come to be known as Crew Resource Management, which takes the principles of group dynamics and human error and focuses on communication and decision-making to lead to more informed, and better, outcomes.
Such training is now required of all commercial airline crews, and it has made its way into the maintenance and air traffic control arenas. The result has been a significant decrease in airline accidents in the U.S. (and other developed countries) over the last 30 years.
Many in the healthcare industry have looked to these principles as a means of reducing medical errors and increasing patient safety. One example is the Veterans Affairs medical system, which now has a former astronaut-flight surgeon in charge of patient safety.
These are not quick-fix solutions. It takes many years to change a culture. However, I can tell you that the personalities of pilots and doctors are not all that different, and if it can happen in the aviation industry, it can certainly happen in the healthcare industry.
Gregg A. Bendrick
Edwards Air Force Base
The writer is chief medical officer at the NASA Dryden Flight Research Center.
The article said that "instead of business as usual," Michigan "followed a plan . . . that involved a simple checklist, fashioned after the kind of safety list pilots are required to check on each takeoff." It is nice to know that hospitals are finally catching up with simple techniques that have been in use for decades.
The article also stated that some hospitals have progressed to using things such as bar codes. Has anyone not been in a retail outlet, restaurant, factory, grocery store or school that does not use bar codes extensively? Bar codes are a 20th century technology.
