Letters Checklist culture

We need a safety system (and an operations manual)

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c917 (Published 23 February 2010) Cite this as: BMJ 2010;340:c917
  1. Nicholas J Toff, airline pilot1
  1. 1Cambridge CB22 4XU
  1. nt{at}toffmail.com

    The recent editorial by Vincent and colleagues struck a chord as I have experience as an anaesthetist and an airline pilot.1 All high reliability organisations have a safety management system, featuring basically the same requirements as clinical governance, with one important addition—an operations manual, which provides concise but authoritative information and instructions on who does what, when, and how. When backed up by good communications and training, the result is a flexible and resilient organisation.

    As the authors say, such reliability and resilience may be approached in some teams and in some parts of health care. But safety systems are important because they are implemented across organisations. Perhaps the absence of an operations manual is indicative of the failure to understand.

    The recent implementation of the WHO surgical safety checklist is a good example. Checklists, used at a crucial point to confirm that vital actions are complete, are familiar to pilots, who assume that such actions have already occurred as part of clearly defined procedures. Unfortunately, this is often not the case. The junior doctor may know that the consultant “likes” antibiotic prophylaxis written up and a protocol may even exist; the anaesthetist will “probably” check the drug chart and may “remember” to give them. Now, if all else fails, it will be caught by the checklist, but I wouldn’t like to be a passenger on an aircraft operated like this.

    I agree that methods and concepts used in aviation and other industries must be applied intelligently and appropriately to health care, and that the healthcare system may be unique in some respects. But I do not agree that health care is so complex that this cannot be done. Unravelling the effects of multiple reforms on management structures, clinical staffing, and training will be challenging, but a systematic approach is possible—there may even be gain without pain, but not without change.


    Cite this as: BMJ 2010;340:c917


    • Competing interests: None declared.


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