Medicine is an inherently risky business. We are oftencompared to the airline industry for our safety profile, but I am not overly fond of that analogy. The overwhelming majority of planes never crash, but all our patients eventually die. Pilots would not fly planes down three of four engines and with a faulty hydraulic system. And mechanics definitely wouldn’t try to fix that plane while it was flying.
We often don’t have a choice. Patients with multiple medical problems are the norm on the inpatient service and they come in with emergencies that need to be addressed immediately. Pilots would not fly at midnight after being up since 6 am; physicians and surgeons may not have a choice. The same problems crop up with nuclear power analogies. However, in their quest to reduce harm, those industries learned a lot about minimizing human error and preventing harm. They learned so much it is now irresponsible of our profession not to learn from them as we strive to make medicine better and safer.
The challenge is that we find ourselves a generation behind. Not only were none of my classmates taught the science of human factors engineering in medical school or residency, many medical schools still don’t cover the material in any depth. Moreover, our ranks are filled with cynics because while techniques to minimize harm and reduce errors are based on good science, none of us were exposed to that science in our training, so of course we are skeptical.
In our effort to make Bridgeport Hospital safer, we joined 23 other Connecticut hospitals and committed to becoming a High Reliability Organization. After a great presentation by Ryan O’Connell, MD, our vice president for Performance and Risk Management, the Medical Staff Executive Committee approved a resolution requiring that all medical staff members with clinical privileges be trained in high reliability and patient safety.
Training focuses on the science of human factors engineering. You’ll learn ways to decrease errors and minimize the harm caused by errors that still occur. It is time to acknowledge we know much about how people make errors and, as we are all human, we must take time to learn how to make our patients safer and our care less harmful. Consequently, over the next year I will periodically write about the science of human factors engineering and how we can decrease our errors and minimize the resulting harm when they do occur.
Michael Ivy, MD
Chief Medical Officer