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There's been a lot of talk for quite some time in healthcare quality improvement circles about why healthcare can't be as safe as airline travel. Some of the reasons behind asking this question are very valid, as there are many things healthcare can learn from the aviation industry. Others, however, are complete fallacy; because on so many levels, it's like comparing apples to oranges.
Over recent weeks, I've heard the debate resurface again, with the same quality improvement thought leaders using the same old arguments, without being grounded in the reality of frontline medicine.
Slowly but surely, patient safety is taking its rightful place at the forefront of American medicine. Ever since the landmark report from the Institute of Medicine in 1999, "To Err is Human: Building a Safer Health System," the issue has been gaining increased traction year on year. Dismal patient safety statistics in some hospitals are correctly being highlighted by the media, with pressure growing on senior leadership and administrators to vigorously address any shortcomings. And not just in this country. Recently, the United Kingdom's National Health Service published a long-awaited review on patient safety, which is hoped will lead to a major cultural shift and philosophy of zero harm for patients.
Hopefully great changes are around the corner. After all, if we cannot feel safe in hospitals, where can we feel safe?
Many of the leading voices of the patient safety movement are quick to draw a comparison with aviation, which has successfully used protocols to make flying a much safer experience over the last few decades. So much so that the airline industry is now considered second to none in terms of safety. I don't doubt the earnestness of such juxtapositions -- from healthcare leaders who are committed to the cause. But as enviable as the aviation industry's achievements may be, I feel that some of our colleagues may be a bit overzealous in drawing frequent parallels. There are in fact many reasons why a straight comparison between aviation and healthcare is extremely limited.
Firstly, and quite obviously on a human level, patients are real living people, whereas an airplane is simply a machine. The importance of human contact, empathy, compassion, a willingness to learn and listen to concerns, and the ability to spend adequate time with patients, will always be the first pillar of promoting a culture of safety and thoroughness in clinical settings. Checklists to improve systems are wonderful in mechanical areas like operative care and inserting central lines, but can only go so far without the most important virtues of being a doctor or nurse.
Second, apart from the first few haphazard days of early flight after the Wright brothers changed the course of human history, flying has always been relatively safe compared to healthcare. Some current reports suggest that as many as 1 in 5 patients are harmed in hospitals. That's a truly staggering and frightening number, and represents a higher baseline from which we need to improve. (For some perspective, even during the darkest days of World War II, Allied airplane losses barely approached such high percentages.)
Aircraft are engineered to be in the best possible shape before they fly. Patients, on the other hand, are in the worst shape when they enter the doors of the hospital. Medicine is by nature, a much riskier practice than flying. The threshold for inflicting harm is therefore much lower, however unacceptably high today's statistics may be.
Third, and perhaps most importantly, airlines -- or, at least, the vast majority of them -- strive for excellent service and will always have staff to serve you promptly during a flight. The pilot will be totally dedicated to flying the plane, and will not fly without the co-pilot and crew. I remember a flight I took from Philadelphia, which was delayed because the airline needed to find an extra couple of cabin crew members. The passengers all waited patiently for well over an hour by the gate, and a loud cheer erupted when we finally saw the airline crew arrive. The plane simply would not take off without a complete set of staff.
On the other hand, many frontline healthcare workers will testify to the fact that patient safety incidents and errors tend to occur when they are struggling with staffing levels and feel grossly overworked. Compare the rest time given to airline staff in between long flights, to the all too common scenario of having over fatigued frontline healthcare staff in clinical settings.
A pilot is also only ever going to fly one plane at a time. Not that it's realistic for a doctor or nurse to be allocated to just one patient, but the workflow is very different, with healthcare tasks frequently interrupted with new clinical issues and emergency situations. Consequently, insufficient staffing can have an acute effect on outcomes and the ability to perform safely. Any healthcare administrator who seriously wants to improve patient safety without first and foremost making sure that their staffing levels in that particular department are adequate, may be doomed to fail (in healthcare's defense, it is much easier to plan for the staffing levels needed for a booked flight than the typical unpredictable day in hospital).
So does all this mean that the aviation industry comparison is completely invalid? Absolutely not. Their safety record is one that we can only hope to emulate over time. But the two industries are vastly heterogeneous, and to say that safety in medicine should follow in the path of flying airplanes, grossly oversimplifies a complex problem. It's highly doubtful that aviation holds all, or even most, of the answers as we strive to make hospitals safer.
Suneel Dhand is an internal medicine physician and author of three books, including. He is the founder and director, , and blogs at his self-titled site, . This post appeared in .