Friday, August 6, 2010

Sullenberger Lectures Hospital Administrators on Safety

The American Hospital Association apparently invited Captain Sullenberger to give them a talk in July on how lessons learned in enhancing aircraft safety could be used to improve the quality of hospital care. He gave them an earful. It must have been an impressive performance. Here are some quotes attributed to him in an article posted by Healthleaders Media.
"Thirty plus years ago, before CRM (cockpit resource management), captains could be alternately Gods or cowboys, ruling their cockpits by preference or whim with insufficient consideration of best practices or procedural standardization…And first officers trying to do the right thing would never quite know what to expect. Some captains did not bother with check lists (and it was unclear who was responsible for what)."

"We worked to build a culture of safety that allows us to face an unanticipated dire emergency, suddenly, one for which we had never specifically trained, and saved every life on board…"
He nails them good with this passage comparing the horrendous consequences of the infrequent aircraft disaster with the unnoticed daily disasters taking place in hospitals.
"But medical mishaps, on the other hand, happen one by one. But as everyone in this room knows, all too well, the mortality in America’s hospitals from accidents and hospital acquired infections is nearly 200,000 people per year in the U.S., or 548 lives a day, the equivalent of two large passenger jets crashing daily with no survivors….(if that happened in aviation) the airline industry would come to a screeching halt; airplanes would be grounded and airports shut down. There would be Congressional inquiries and companies would go out of business."Then he points out that most medical errors are the result of system failures. Just as in the aviation industry, safety required the development of a culture where all participants were viewed as members of a team. A comparison is implied between the cowboy pilots of yesteryear and the doctors of today who choose not to bother with checklists, then he goes on to decry the current medical situation where it is assumed that when something goes wrong it is the result of an individual’s error.
"Conventional wisdom often has it that if a nurse makes a mistake, he or she should be terminated, but the vast majority of harmful events are due to system failures not practitioner error. The (health care) leaders are responsible for the maintenance of these support systems, not the caregivers. And the current punitive culture only drives problems underground where they can never be examined or solved."

"Federal legislation is about to link health care payments to the quality of service. I believe in ten years, when this is integrated throughout the system, we’ll look back at where we are today and will know that we were flying blind."
It was said the Sullenberger was accorded a standing ovation at the end of his presentation. He deserved one! Hopefully these hospital administrators will take to heart what he told them.

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