Ending medical errors with airline industry's help
WHEN I was a young surgeon, one of my patients nearly died and I was responsible. The incident had nothing to do with my surgical skills and everything to do with my lack of leadership.
The patient's airway was obstructed by a massive tumor and he needed an emergency tracheotomy. Flush with confidence from five years of surgical training and two years in the military, I could foresee no problems that I couldn't handle. Why bother going over my plan of care with the nurses or the anesthesiologist?
Just as the patient was being prepped for surgery, he went into cardiac arrest. The anesthesiologist, inexperienced in the procedure, was helpless to reestablish an airway. The regular nurses were unavailable, and their hastily selected replacements had never worked together in the operating suite on this procedure. I found myself marooned, shouting a flurry of commands at a team too paralyzed to act.
In the end, I was able to open an airway by performing a tricky and dangerous throat operation, and then restore our patient's heart function. I helped save him but I was no "hero." The untenable situation I had faced was largely of my own making. I had neglected to evaluate the skills of my team, prepare the team members, and plan for contingencies. Despite my military training, I had failed my first test of leadership.
Unfortunately, such incidents are none too rare. Each year, medical errors harm 15 million patients and contribute to 100,000 deaths. In many cases, they are caused by a lack of communication, inattention to details, poorly coordinated resources, and inadequate planning.
Since that day, I have moved to a different hospital, worked with new crews, taught medical students, and studied ways to improve surgeon training. I have come to realize that while we surgeons are trained to be outstanding technicians, little has been done to teach us effective leadership and communications skills.
Who can coach surgeons to be more effective leaders? My answer may come as a surprise: commercial airline pilots.
Commercial airlines have developed a poor reputation in recent years on a variety of issues, such as frequent delays and poor service, but they excel in one area: safety. Flight crews have learned to make fewer errors. This improved safety record is due not to better technology or more highly skilled pilots, but to a leadership and team training approach called "crew resource management."
In the 1970s, after flight crew errors spawned a run of airplane crashes, psychologists were brought in to examine what was going wrong. They found, among other things, crew members who were afraid to speak up about potential problems and captains who were overly protective of their authority. Their findings prompted the airlines to develop a new approach that encouraged participation by all team members while maintaining respect for the captain's authority. This meant holding preflight briefings, setting standard operating procedures, running through checklists, and creating an open environment. Better performance and increased safety resulted.
Flying a jet and cutting out a tumor both require teams distinguished by a high degree of precision, coordination, and reliability. For both, it's often the little things that mean the difference between success and disaster.
Operating rooms suffer from the same flaw that once plagued cockpits: Just as crew members had feared questioning their captains, many surgical team members still fear questioning surgeons. Many medical errors could have been avoided if a nurse, resident, or anesthesiologist had felt free to speak up.
What works in the cockpit can work in the operating room. More hospitals are making it standard practice to hold pre-operative briefings to discuss the procedure, the patient's risk factors, and contingency plans, and then run through checklists before beginning the procedure. There is a movement in medicine to establish best practice guidelines developed from evidence-based research - what pilots call "standard operating procedures." The American College of Surgeons is helping to establish these best practices; in addition, it is offering educational programs and seminars in crew resource management and is building awareness and acceptance of the value of this approach across the country.
Team training works: At my department at Children's Hospital of Boston, our medical error rates have dropped to zero after airline pilots taught us team training, and team training resulted in lower death rates and more satisfied patients in the cardiac surgery program at another New England hospital.
The lesson I learned the day my tracheotomy patient nearly died is one that I carry with me to this day. As individuals, we are prone to making mistakes; but as part of high-performance teams, we can avoid or minimize those mistakes. And that means better patient outcomes.
Gerald B. Healy is otolaryngologist in chief at Children's Hospital in Boston, professor of otology and laryngology at Harvard Medical School, and president of the American College of Surgeons.
