Intended for healthcare professionals

Editor's Choice

Human as hero

BMJ 2009; 338 doi: (Published 22 January 2009) Cite this as: BMJ 2009;338:b238
  1. Fiona Godlee, editor, BMJ
  1. fgodlee{at}

    Speaking last week at a lecture in his honour hosted by the National Patient Safety Agency, James Reason, the world expert on human error, said he was shifting his focus from “human as hazard” to “human as hero,” a species capable of heroic attention to detail. The very next day ex-fighter pilot Chelsey B Sullenberger became America’s perfect hero with his textbook landing of a stricken passenger plane on the Hudson River.

    The lecturer was Atul Gawande, surgeon, writer, and global champion of patient safety. He held the packed hall spellbound. “I think of medicine as a test of our ability to manage extreme complexity,” he said. His message was that medicine’s complexity has now overwhelmed the ability of individuals to manage it, however expert and specialised they may be. As a result basic steps are missed and patients die. He told the story of Boeing’s long distance bomber, the B-17 Flying Fortress, which made possible the precision bombing of Germany from 1943 to 1945. But the plane nearly didn’t make it into mass production. Its 1935 demonstration flight to US military chiefs ended in disaster when the air crew forgot to unlock the elevators on the tail. The huge four engine aircraft crashed and burned on take off killing both pilots, their undoubted skills and training unable to save them or the plane.

    What retrieved the plane from the scrap heap and secured its place in history was a simple pre-flight checklist. The question is whether we in medicine are ready for similar salvation. I think we have to be. A paper published last week in the New England Journal of Medicine, co-authored by Gawande as part of the World Health Organisation’s World Alliance for Patient Safety, found that a 19 item perioperative checklist significantly reduced postoperative complications and deaths (doi:10.1136/bmj.b157). As the authors and our editorialists (doi:10.1136/bmj.b220) explain, the study has limitations. But the methodology is sufficiently robust and the results are sufficiently impressive to justify the NPSA’s commitment that the checklist should be implemented for all operations in England and Wales by February 2010.

    Later this year WHO will launch its checklist for labour and delivery, and beyond that lies the prospect of checklists for a range of medical emergencies. Mandating their use will speed up adoption, but we should also try to win hearts and minds. There will be resistance to adopting something as prosaic as a checklist. Early adopters will already be using them. Others will be convinced by the New England Journal study. Yet others will want data from their own practice. But some will see checklists as an affront to their professionalism and will never be convinced. At some stage, perhaps sooner rather than later, they will have to go. We shouldn’t be conned by Hollywood’s version of the hero—the maverick loner who saves the day by breaking all the rules. Instead let’s look to the hero of the Hudson River. He and his crew had skill and experience as well as luck on their side, but they had also trained teams for this extremely rare scenario, and they knew exactly what to do.


    Cite this as: BMJ 2009;338:b238

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