Flight school:learning lessons from aviation

It has been estimated that every three days the equivalent of a 747 planeload of passengers lose their lives because of human error in medicine. This staggering figure (44 000-98 000 a year), unveiled in a landmark report by the US Institute of Medicine in 2000, made preventable medical error the eighth most common cause of death in the United States.1 In the United Kingdom, however, the estimated figure is not so high. In July 2005, the UK National Patient Safety Agency published their first public analysis of patient safety data. From incidents reported by all sectors within the British NHS (75% of incidents reported originated in acute trusts however, so this data may not be representative of the NHS as a whole) in England and Wales, it was estimated that about 1 in 100 of all reported incidents resulted in severe harm or death, which corresponds to about 840 deaths a year.2

In light of these statistics and a litigious society, it is tempting to focus on attributing blame, but blaming an individual does not change the multiple factors that can lead to preventable medical error, and means that the same error is likely to occur again. It is perhaps not so much the people at fault, therefore, as the system, although obviously there are exceptions. Substantial research programmes are underway to reduce the incidence of preventable error. In the UK this responsibility is assumed by the National Patient Safety Agency, which was created in 2001 after the chief medical officer's report on patient safety.3 Progress has come from the careful analysis of the system (people and machines) and the environment, a process that is encompassed in a discipline …