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Views And Reviews

Improving patient safety: we need to reduce hierarchy and empower junior doctors to speak up

BMJ 2019; 366 doi: (Published 02 July 2019) Cite this as: BMJ 2019;366:l4461
  1. Peter A Brennan, consultant maxillofacial surgeon and honorary professor of surgery1,
  2. Mike Davidson, pilot and union representative2
  1. 1Queen Alexandra Hospital, Portsmouth, UK
  2. 2British Airline Pilots Association
  1. peter.brennan{at}
  2. Follow Peter on Twitter @BrennanSurgeon

Empowering doctors to speak up when they have concerns is essential to making our NHS safer, say Peter Brennan and Mike Davidson

Aviation and medicine are sometimes compared, but in reality are fairly diverse professions. Unlike medicine, in aviation one mistake can result in large scale loss of life. Healthcare can still, however, learn a lot from aviation and other high risk organisations, particularly in how they’ve embraced and applied human factors, the importance of looking after ourselves at work, and reducing hierarchy.

Analysis of cockpit voice recorders has historically shown that the majority of pilot related errors were because of failures of interpersonal skills, communication, decision making, and leadership. In particular, the steep hierarchy that existed between captains and co-pilots was well known as a safety threat, with several fatal crashes occurring as a result of this power dynamic and the communication barriers it created. Indeed, the crash of a United Airlines DC8 in Portland in 1978 was an important driver in introducing what was then called cockpit resource management. Through such training and the understanding of how human errors impact safety, aviation has slowly managed to change its culture. Yet, sadly, the equivalent steep “cross cockpit gradient” still exists in many healthcare teams.

Today, the most senior captain could be disciplined if …

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