Head To Head

Have we gone too far in translating ideas from aviation to patient safety? No

BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.c7310 (Published 14 January 2011) Cite this as: BMJ 2011;342:c7310
  1. David M Gaba, associate dean for immersive and simulation based learning and private pilot
  1. 1Stanford University School of Medicine, Simulation & EdTech, 291 Campus Drive, LK300, Stanford, CA  94305-5217
  1. gaba{at}stanford.edu

James Rogers (doi:10.1136/bmj.c7309) thinks that attempts to learn from aviation are ignoring fundamental factors in healthcare, but David Gaba argues that much more could be done

Analogies between medicine and aviation have been made on two levels: human factors and industry or institutional. Neither has gone too far. The human factors addressed include dynamic decision making in critical situations, team management and teamwork in acute care teams, management of fatigue, use of cognitive aids (such as presurgical checklists, equipment checkouts, and emergency procedures), optimising the physical and electronic work environment (data displays, user interfaces, alarms, etc), and safety culture.1 2 3 4

The analogies have worked particularly well for aspects of healthcare that mirror the cognitive profile of aviation pilots and controllers—those involving sick patients with rapid clinical change, interleaving of diagnosis and treatment, invasive procedures, and heavy use of technology. Thus in specialties such as anaesthesia, intensive care, emergency medicine, surgery, endovascular interventions, and neonatology the translation of ideas from aviation has been successful because it relates to fundamental human challenges of work that is cognitively similar between domains.1 2 3 4 There is extensive literature in healthcare peer reviewed journals on these topics, and typically the analogous practices in aviation long pre-date their incorporation into healthcare.

Further potential

It is true that concepts and practices from one domain cannot be transferred directly to another; translation or adaptation is needed to ensure that the fundamental characteristics of healthcare are considered properly. Such translation has been successful for many concepts in many domains of healthcare, but not all attempts will work; nor will they work for every healthcare setting or every problem of patient safety.

Nonetheless, if we accept that some concepts have been reasonably translated from aviation to healthcare, how far have we gone in actually implementing those practices? We haven’t gone very far, surely not far enough, and by no means have we gone too far. Examples are legion. Checklists are widespread and mandatory in aviation; the notion of a simple checklist before surgery is beginning to be implemented but adoption is still extremely variable. Pilots are under strict limits for work hours. In the United States, we impose limits on work hours for medical trainees (mild limits by European standards), but we have no limits for experienced staff. Simulation is a regular part of training and assessment for airline pilots. While it is beginning to become commonplace for medical trainees, the number of practising doctors—let alone teams of doctors and nurses—who have participated in an intensive simulation remains tiny. In aviation, best practices determined by regulators and individual companies are uniformly adopted by pilots and controllers. In healthcare even widely accepted evidence based best practices are often not adopted uniformly.

Moreover, I would argue that we have been too superficial in our approaches. Take fatigue. No one seriously believes that it is wise for clinicians to be dead tired when they perform potentially dangerous work on patients. Healthcare has superficially grafted fixes to the problem of sleepy clinicians without seriously redesigning clinical work processes or the structure of the clinical workforce. Is it any surprise that putting a sticking plaster on a large wound doesn’t work very well? What is really needed for this, and many other problems, is fundamental reconsideration of how clinical work is organised rather than arguing about the source of ideas for change.

Wider comparisons

The second level of analogy concerns larger issues of aviation versus healthcare as industries.5 6 7 Both aviation and many parts of healthcare are of high intrinsic hazard. Evolution certainly didn’t intend for human beings to be up in the air. Many endeavours in healthcare—anaesthesia being one obvious example—are equally unnatural and likely to cause harm if not controlled carefully. The unmatched safety of commercial aviation (for US airlines scheduled service 2000-9: 0-1 fatal accidents a year or 0-0.017 per 100 000 departures a year) is testament to the effort that has gone into making what is fundamentally dangerous into something that is incredibly safe. Healthcare is nowhere near to achieving such results, even for elective care.

Clearly though, there are limits to the comparison of aviation and patient safety. It is important to distinguish the intrinsic differences between these arenas from the differences that are due only to traditional structures and practices. One fundamental difference is that unlike aeroplanes, we don’t design and build human beings; we don’t even receive the instruction manual. Another fundamental difference is that for commercial aviation many lives are at risk in each flight, whereas in medicine we typically have only one. Thus, airline accidents are highly public whereas most iatrogenic adverse events remain private. Conversely, many differences are not fundamental but are contingent solely on historical factors of organisation, such as the job types of “doctor,” “nurse,” and their scopes of practice, or what degree of standardisation is realistic in healthcare.

Yes, for every programme there are costs and benefits as well as unintended consequences to consider. These should be analysed for any intervention whether it is translated from another industry or comes directly from a healthcare source. Healthcare will never be the same as aviation. It can’t be. Patients are indeed not aeroplanes. But our pendulum of safety management is so far from that of aviation that we surely don’t need to make healthcare exactly like aviation, and no credible source has ever suggested that we should. Instead, those of us who have advocated learning lessons from aviation have sought a middle ground, recognising and adapting appropriate concepts and practices and implementing them sensibly into healthcare. The process of finding those concepts and practices has not finished, and the implementation of those practices that seem most likely to be beneficial has barely scratched the surface.

Notes

Cite this as: BMJ 2011;342:c7310

Footnotes

  • Competing interests: The author has completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organisation for the submitted work; DMG is editor in chief of Simulation in Healthcare and receives an annual stipend for this from the Society for Simulation in Healthcare; he is an unpaid member of the board of directors and executive committee of the Anesthesia Patient Safety Foundation.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

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