Delivering safe health care
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7313.585 (Published 15 September 2001) Cite this as: BMJ 2001;323:585
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The British Medical Journal has shown leadership in examining medical
error. Often,in articles examining error the airline industry is held up
as
an example as how efforts to eliminate medical error can be successful. In
light of the recent tragic events I wish to offer the following analysis
for consideration.
Prior to Sept 11 the airline industry needed only to concern itself
with
the safety of those in the air. Now, the safety of those on the ground
beneath the planes is also of great concern. To use a medical analogy,
prior to Sept 11 the airline industry needed only to concern itself with
the health and well being of individual patients. The safety of the
general
public was not a factor for consideration. Now, obviously, terribly, and
tragically, the airline industry has a public health dimension that must
be
closely attended to and will no doubt be the subject of intense and
painful
scrutiny.
There are two possible lessons from the events of Sept 11, one for
the
airline industry that is obvious, the second for the health care industry
that is less so. First, the airline industry has painfully learned a
lesson
known to all experienced clinicians; you cannot avoid outcomes that exist
outside of the realm of conception. Second, those involved in a health
care
industry that is for the most part intensely focused upon the well being
of
individual patients should also contemplate the recent events. Perhaps
public health concerns should be pursued every bit as vigorously as
efforts
to improve the health and well being of individual patients.
Stephen Workman MD FRCP(C)
Assistant Professor
Dalhousie University Department of Medicine
Competing interests: No competing interests
Dear Sir,
I have long been interested by the comparisons which are made between
medicine and aviation, such as the one made in this article, which
compares healthcare safety to carrier flight deck operatations. I believe
that if the authors, and others who have made similar comparisons,
understood aviation safety in greater detail, they would be less likely to
make such comparisons.
Pilots are usually only certified to fly one particular type of aircraft,
often only a sub-type of that plane, for example, the 400 series of a
Boeing 737, but not the 800 series. In addition, they usually work in
pairs, with a co-pilot backing up all cockpit decisions on the majority of
commercial flights. Navigation is under the control of twin flight
computers, loading flight plans which are programmed by external experts,
and the most dangerous phases of flight, approach and take-off, are done
under the control of Air Traffic Controllers. There are published
procedures for taking off and landing at airports, and on carriers, which
must be rigidly adhered to. Planes have to be serviced at regular
intervals, and at great expense.
Compare this to medicine. The domain of knowledge is virtually unlimited
compared to aviation, much risk is uncontrolled due to the impossibility
of writing procedures which cover all the variables involved, and patients
are free to smoke, drink, take drugs and overeat as part of the freedoms
of a democratic society. The general public would be shocked if planes
were treated the way they treat their own bodies, and would refuse to fly,
I suspect.
So while there are lessons to be learned from aviation, it is simplistic
to take aviation safety as a parallel, and given that the BMJ has banned
the use of the word "accident" from its pages, I would suggest that it
takes a similar line with comparisons with aviation safety. By all means
make them, but can authors please take greater care to understand what
they are comparing?
Andrew Herd
Competing interests: No competing interests
"For example, inadequate handovers can mean that vital information is
lost between different care givers and services." Yes, communication is
important, and certainly this message was given my class as students,
and during intern orientation over 20 years ago.
Why then, is it still common to have no handover time included in
medical rosters? Emergency Department staff and night-shift medical
registrars work night shifts which are often longer than day shifts, with
pressure to delay referrals to colleagues "on-call" until the morning,
and to keep patients in the ED overnight when beds are scarce.
If management believe that something is important, they must allocate
resources for it. There is no failure of "medical schools and training
programs..to include safety of patients as a central objective" - the
failure of implementation is elsewhere.
Competing interests: No competing interests
A Feminist Approach to Health Care Safety
To ensure the health care safety for patients, this project
recommends a feminist approach in advocating the significance of ownership
of the body and of deconstruction of the notion of patient. This is
not a project focussing on strategic health care safety. Rather, it is
a philosophical way of thinking with the objective of enhancing nurses to
formulate and implement their specific actions in the historical
sociocultural context in order to promote a safety environment as well as
to prevent a potential hazard for patients in two ways.
Firstly, empowering the patients to have a concept of bodily
ownership by rethinking who owns the body. Furthermore, enhancing the
patients to realize that they have the right and obligation to carry out
their health care safety. Secondly, deconstructing the dichotomy of
patient and health profession by revisiting what the meanings of patients
are.
Furthermore, promoting a collaborative atmosphere where it can
facilitate a partnership approach to health care safety. I suggest
unmasking professional bias to reveal patients' experience so as
to construct a humanistic health care safety environment through the
issues of health care safety.
Competing interests: No competing interests