'Miracle on the Hudson' offers safety lessons
In 2009, Jose Gonzalez, MD, the medical director for the Texas Medicaid/State Children's Health Insurance Program, discovered the devastating results of a medical error in a very personal way. When his niece, Kaelyn Sosa, then 18 months old, was brought into a Miami hospital after receiving a bump on her head from a fall, she was sedated and given an MRI. During the test, her breathing tube became dislodged, resulting in a severe brain injury.
Gonzalez says cases like Kaelyn's are all too common in the United States and some patients don't even leave the hospital alive. Nearly 100,000 people die every year in hospitals and doctors' offices due to medical mistakes. It's a huge number: Put in perspective that's the equivalent of one fully loaded 747 crashing every single day for a whole year, he notes.
The frequency of medical errors hasn't motivated enough hospitals and other health care facilities to take action, and that's a message being spread by Gonzalez and his niece's parents, Ozzie and Sandy Sosa. So when Gonzalez saw Stephen Harden, an aviator and CEO of LifeWings in Memphis, TN, speak on the issue of patient safety and systems for change, he knew he needed to invite the expert to Texas.
Harden presented "Meeting the Unspoken Expectation of Safety: What Every Clinician Can Learn from the Miracle on the Hudson and the Ditching of Flight 1549" at the recent Texas Pediatric Society Annual Meeting in San Antonio. Harden's organization has adapted the best practices of high-reliability organizations such as commercial aviation, U.S. Navy aircraft carriers, and nuclear power to help more than 100 health care organizations provide the highest safety for their patients.
Gonzalez says he can see the value in adopting the best practices of high-reliability organizations in health care, especially the concept of "crew resource management," which encourages pilots and other professionals to work closely as a team.
"Had the back-up systems and cross-check we use in commercial aviation been in place when Kaelyn was being treated, the dislodged tube would very likely have been discovered and her brain damage prevented," Harden says. "The one thing we know from aviation is that people will make mistakes; a good safety system recognizes people aren't perfect and will catch their mistakes before they harm the patient."
Not just a miracle
Harden tells Healthcare Risk Management that the "Miracle on the Hudson Flight" is a good illustration of how an organization can prepare for the inevitable accidents that will occur but still avoid disaster. US Airways Flight 1549 had just departed from New York City to Charlotte, NC, on January 15, 2009, when it was disabled by striking a flock of Canada geese during its initial climb out. The bird strike resulted in an immediate and complete loss of thrust from both engines. When the aircrew of the Airbus 320 determined that they would be unable to reliably reach any airfield from the site of the bird strike, they turned it southbound and glided over the Hudson.
The pilot and co-pilot successfully ditched in the Hudson River adjacent to midtown Manhattan six minutes after takeoff. All 155 occupants safely evacuated the airliner, which was still virtually intact though partially submerged and slowly sinking, and were quickly rescued by nearby watercraft.
"The whole event is commonly called the Miracle on the Hudson, but I take a contrarian view to calling it a miracle," Harden says. "Rather than being a miracle, it is a great example of the adage that systems are perfectly designed to get the results they produce. That is a message that resonates well in risk management and quality improvement in health care, because any system in their hospital is perfectly designed to get the results it produces."
There was some good fortune involved in the successful ditching of Flight 1549 good weather and a daytime flight and certainly great skill from the crew, but Harden says the underlying safety system design factors in commercial airliners are the real reason all 155 people came away with nothing worse than wet shoes.
Teamwork is essential
Harden says there are three important lessons from the Miracle on the Hudson:
Everyone on the team must have expert teamwork and communication skills. Look at any group of highly trained professionals within the organization, and ask whether it is merely a group of experts or whether it is an expert team.
"The crew on that airplane were [an] expert team, and they got that way through their training," Harden says. "You didn't just have two pilots up there who independently of each other were very qualified in their jobs. You had two pilots who knew how to work seamlessly as a team."
The organization must use what Harden calls "hard-wired safety tools." These would be checklists, communication scripts, and standard operating procedures that "hard wire" the proper safety procedures.
"If you use these safety checklists or these scripts, you have no choice but to use good teamwork, because the teamwork is built into the checklists," he says.
The organization's leadership must enable people in the organization to use teamwork and safety tools. In other words, the leadership must make those resources available and support their use in every way.
Even with all the emphasis on patient safety in recent years, the health care industry has not sufficiently adopted the principles of high-reliability organizations, Harden says. The primary cause of patient harm is a breakdown in interpersonal relations, teamwork, and collaboration, he notes, accounting for about 70% of all adverse events.
That figure has been relatively unchanged over the past 10 years, he says. Root cause analyses frequently trace back to communication breakdowns, yet the health care industry still has been slow to adopt the same techniques that produced the Miracle on the Hudson, he says.
"If you look into the root cause, it's not uncommon to find that somebody on the team had a concern, a feeling in their gut, that something was not right," he says. "When you ask them after the patient has been harmed why they didn't speak up, they tell you that they didn't think administration would support them if they stopped the line or they thought some doctor would bite their head off."
But when you ask the physicians and supervisors whether they expected the employee to speak up, they always say yes, that they encourage that kind of initiative, Harden says. When asked to show where they put that expectation in writing, most can't provide evidence, he says.
"If you want someone to speak up and be assertive if they detect something that is unsafe or not in the best interest of the patient, it's hard to find that kind of language in a policies and procedures manual saying it's a requirement," Harden says.
Must reward employees
Providers also are lax about including such a requirement in their new hire training and inservices, Harden says. They also are remiss in rewarding employees who do speak up by putting a positive notation in their personnel files, he says.
"We don't require it in the policies and procedures manual; we don't train them in teamwork when we hire them; and we don't reward them when they do it; and we don't check that they can do it in their annual performance reviews," Harden says. "Is it any wonder why you're not getting that behavior at the moment of truth? Leadership has done nothing concrete to [foster] that teamwork and make sure that kind of behavior is sustained over time."
Many industries are adopting the high-reliability practices that have proven successful in aviation and other fields, and Harden encourages risk managers to push for a focused effort to improve teamwork. As experience in other fields has shown, merely saying you encourage teamwork is not enough. The health care organization must implement concrete steps to make teamwork a necessity rather than just a good idea, he says.
The tools for health care teamwork may have to be the first objective. Harden believes checklists and similar tools have not been used as extensively in health care as in other industries, because they have not been well-designed.
"Our health care professionals are some of the best in the world, so it's not a matter of lacking expertise or not wanting to do what's right for the patient," Harden says. "It's a question of developing a system that allows them to work together as an expert team. That has not really taken hold across the health care industry, and it has to if we want to see more Miracle on the Hudson type endings when something goes wrong."
Stephen Harden, CEO, LifeWings, Memphis TN. Telephone: (800) 290-9314. Web site: www.saferpatients.com.
Jose L. Gonzalez, MD, Medical Director, Texas Medicaid/SCHIP HHSC/OMD, Austin, TX. Telephone: (512) 491-1325. E-mail: Jose.Gonzalez5@hhsc.state.tx.us.