CLINICIAN’S CORNERFROM THE ARCHIVES JOURNALSABSTRACT AND COMMENTARY

Solutions for Improving Patient SafetyARCHIVES OF SURGERY

Can Aviation-Based Team Training Elicit SustainableBehavioral Change?

Harry C. Sax, MD; Patrick Browne, BMil; Raymond J.Mayewski, MD; Robert J. Panzer, MD; Kathleen C. Hittner,MD; Rebecca L. Burke, RN, MS; Sandra Coletta, MBA

Objective: To quantify effects of aviation-based crew resourcemanagement training on patient safety–related behaviors andperceived personal empowerment.Design: Prospective study of checklist use, error self-reporting,and a 10-point safety empowerment survey after participationin a crew resource management training intervention.Setting: Seven hundred twenty-two–bed university hospital;247-bed affiliated community hospital.Participants: There were 857 participants, the majority ofwhom were nurses (50%), followed by ancillary personnel(28%) and physicians (22%).Main Outcome Measures: Preoperative checklist use overtime; number and type of entries on a Web-based incidentreporting system; and measurement of degree ofempowerment (1-5 scale) on a 10-point survey of safety

attitudes and actions given prior to, immediately after, and aminimum of 2 months after training.Results: Since 2003, 10 courses trained 857 participants inmultiple disciplines. Preoperative checklist use rose (75% in2003, 86% in 2004, 94% in 2005, 98% in 2006, and 100% in2007). Self-initiated reports increased from 709 per quarter in2002 to 1481 per quarter in 2008. The percentage of reportsrelated to environment as opposed to actual events increasedfrom 15.9% prior to training to 20.3% subsequently (P� .01).Perceived self-empowerment, creating a culture of safety, roseby an average of 0.5 point in all 10 realms immediatelyposttraining (mean [SD] rating, 3.0 [0.07] vs 3.5 [0.05];P� .05). This was maintained after a minimum of 2 months.There was a trend toward a hierarchical effect with participantsless comfortable confronting incompetence in a physician(mean [SD] rating, 3.1 [0.8]) than in nurses or technicians(mean [SD] rating, 3.4 [0.7] for both) (P� .05).Conclusions: Crew resource management programs caninfluence personal behaviors and empowerment. Effects maytake years to be ingrained into the culture.

Arch Surg. 2009;144(12):1133-1137

Commentary by Edward H. Livingston, MD

NEARLY A DECADE AGO, THE INSTITUTE OF MEDI-cine (IOM) published “To Err Is Human” high-lighting the frequency of preventable deaths dueto medical errors.1 According to the IOM, as many

as 98 000 patients per year die needlessly in US hospitals.Adopting a more rigorous safety culture should eliminatethese deaths. Given the natural inclination of the medicalcommunity to promote good care and avoid harm, it wasexpected that medicine, as a profession, would have em-braced changes to prevent these errors. Five years after thereport was issued, an overview of the effects of the reportdemonstrated that little change had occurred.2 A decade hasnow passed since the IOM publication and medical errors

remain common, leading some to recommend governmentintervention.3 The slowness to rally around patient safetyhas been ascribed to inadequate accountability. Recommen-dations have been made to deliver harsh penalties to thosewho fail to comply with patient safety guidelines.4

Is this strategy necessary to ensure patient safety? Notlikely, because physicians already work in a highly account-able environment. Medical care is subject to oversight bypeer review proceedings and medical board evaluations ofadverse events. Errors made by physicians may result in liti-gation that is expensive and potentially career limiting. How-ever, fear of litigation or serious harmful publicity doesnot necessarily result in improved attention to patientsafety. For instance, several infants treated at Cedars Sinai

Author Affiliations: Division of Gastrointestinal and Endocrine Surgery, Univer-sity of Texas Southwestern Medical Center, Dallas. Dr Livingston is also Contrib-uting Editor, JAMA.Corresponding Author: Edward H. Livingston, MD, University of Texas South-western Medical Center, 5323 Harry Hines Blvd, Room E7-126, Dallas, TX 75390(edward.livingston@utsouthwestern.edu).

CME available online at www.jamaarchivescme.comand questions on p 180.

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Hospital, in Los Angeles, California, were given exces-sively high doses of anticoagulants due to a dosing error. Awell-known actor’s involvement in these events resulted inwidespread media coverage. The hospital was investigatedby the California Department of Public Health and settledwith the hospital for $750 000.5 While this episode was evolv-ing, another major safety lapse occurred at Cedars Sinai Hos-pital. Radiation dosing for head computed tomography scan-ners was increased 8-fold over recommended doses; beforethe error was identified, 206 patients received sufficientradiation so that many experienced hair loss.6 On the otherside of the United States, 5 wrong-site surgeries occurredat a single Rhode Island hospital. During the 21⁄2-yearperiod in which these errors were investigated, the hospi-tal was sanctioned by the state medical board and fines werelevied.7 Despite these actions, the errors continued tooccur.

Slow progress in adopting practices intended to reducemedical errors requires further analysis. Fear of reprisal isnot working. Perhaps physicians have a sense of invincibil-ity that erroneous actions will be committed by others andnot themselves. They may also be suspicious of certain pa-tient safety advocates (ie, government agencies and insur-ers whose motives may not seem pure to the practicing phy-sician). Another possibility is that with lower reimbursementrates and increased bureaucracy associated with medical prac-tice, physicians simply do not believe they have the time todevote to safety training courses and additional practicesadopted in the name of safer practices.

Physician-driven processes for change are more likely tosucceed. A prime example has been the Veterans Adminis-tration (VA) National Surgical Quality Improvement Pro-gram (NSQIP). The NSQIP was started by a small group ofsurgical leaders within the VA who were anxious to pro-vide better outcomes for their patients. The project was ini-tially resisted by their colleagues who legitimately feared thataggregated outcomes data might be misinterpreted and usedto penalize clinicians charged with caring for very sick, high-risk patients. Administrators were not enthusiastic about theprogram because of its expense (Ralph G. DePalma, MD,former National Director of Surgery, Veterans Health Ad-ministration, written communication, December 2009). Withtime, the process of assessing and acting on risk-adjustedoutcomes information resulted in substantial reductions inmortality in the VA health care system.8 As the program’ssuccesses became evident, it became accepted by surgeonsand administrators and has been adopted by the AmericanCollege of Surgeons as its principal means for monitoringsurgical care quality. The NSQIP’s success concurrent tostalled efforts to promote patient safety in other clinical ven-ues most likely reflects the differences between the top-down appeal of a government body (the IOM) and the bot-tom-up implementation of the NSQIP. Improvement in thesafety culture in medicine will more likely succeed if theimpetus for change comes from clinicians and their profes-

sional societies rather than from governmental bodies or in-surance companies.

Two recent articles9,10 in the Archives of Surgery address pa-tient safety issues. Neily et al9 presented findings from the VApatient safety database. Mimicking the National Aeronauticsand Space Administration’s no-fault reporting system, the VAdeveloped an anonymous no-fault reporting system for nearmisses and adverse events. This enabled the VA to fully char-acterize adverse events and near misses. Most error reduc-tion efforts such as the use of time-outs have been imple-mented in operating rooms (ORs) because of the significantpotential for mistakes to occur during surgery and the highprofile of surgery-related mistakes. The VA found that onlyhalf of the reported events came from the OR environment.Wrong-site procedures occurred in non-OR settings such asradiology but also during dental procedures and thoracente-sis. Patient misidentification was relatively common in non-ORsettings highlighting the need to adopt the rigorous patientidentification standards implemented long ago in ORs.

Ophthalmologists and orthopedic surgeons experienced thehighest rate of preventable adverse events (1.8 and 1.2 eventsper 10 000 operations, respectively) resulting not only fromwrong-site procedures but seemingly high rates of incorrectdevice implantation. Root cause analyses demonstrated thatcommunication problems were the most frequent cause ofpreventable errors.5 The VA implementation of a system-wide mechanism for no-fault reporting has done a great dealto show that adoption of risk-free communication amonghealth care workers can achieve the same results as wereproven effective in the airline industry for enhancing safetyawareness. From this VA analysis, the source for prevent-able errors was identified leading to a pathway for error re-duction. Use of communication tools such as checklists andmore rigorous attention to patient identification in non-ORsettings can reduce preventable medical errors.

In an article in the December issue of the Archives of Sur-gery, Sax et al10 reported results of implementation of an air-line industry safety practice to medical care. Crew re-source management training is now standard within theairline industry. Crew resource management was devel-oped following investigations in which poor communica-tion was identified as the leading cause for fatal crashes. Asthe report by Neily et al9 demonstrated, inadequate com-munication is one of the most important causes of prevent-able medical errors. Adoption of crew resource manage-ment in the medical environment seems logical as a meansfor error reduction. Crew resource management includesreview of detailed checklist prior to flying and also incor-porates processes ensuring free and open communicationbetween all members of a flight crew, especially facilitatingsubordinate employees’ ability to openly discuss concernsthey have about flight safety with those in the upper hier-archical ranks. Procedures are used to ensure faultless er-ror reporting ensuring that process improvement takes pre-cedence over assignment of blame.

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Sax and colleagues10 report their experience with imple-mentation of these same techniques in the OR environ-ment. Use of preoperative checklists increased to 100%, er-ror reporting doubled and, in general, those working in theOR environment felt more empowered to address deficien-cies they noticed. Processes such as those outlined by Saxet al will, by necessity, become routine components of dailypractice.6

More must be done to eliminate preventable medical er-rors. Despite IOM reports and numerous editorials high-lighting the need to adopt a stronger safety culture in medi-cine, little has changed. It is natural to resist change. Theinitial reaction to the IOM report 10 years ago was denial.The report was widely perceived as having exaggerated theproblem of preventable deaths. Nevertheless, reports ofwrong-sided surgeries recently have attracted more atten-tion because they are universally viewed as completely pre-ventable and unacceptable; this problem can no longer beignored. The report by Neily et al9 shows that completelypreventable errors occur as frequently in the OR as outsideof it, requiring all health care professionals to engage in pro-cesses to eliminate preventable error.

Because denial of the patient safety problem is no longeran option, how will the safety culture improve in the deliv-ery of medical care? Analogies to the airline industry are use-ful. Crew resource management processes were developedand widely accepted within the industry following high-profile preventable crashes. If passengers lose confidencein the safety of air travel, they will not fly. Public confi-dence in airline safety is an essential foundation of the air-line industry business model. Even though patients are lessafraid of hospitals than airplanes, nonetheless, high-profileincidents such as those that occurred in Los Angeles, Cali-fornia, or Rhode Island still generate concern.

Change might be driven by patients. In the future, phy-sician and hospital selection by patients may be made, in

part, by their safety reputation. Although preventable er-rors are rare, processes adopted to minimize their risk arenot and are readily measurable. Clinician participation inteam training and the use of checklists and other devicesproven to lessen the risk for preventable error might pro-vide evidence for health care organizations’ seriousness aboutpatient safety. Much as today’s quality indicators are reallymeasures of processes of care rather than outcomes, pa-tient safety efforts can be documented by physician partici-pation in these activities. Publication of compliance withpatient safety measures similar to what the Centers for Medi-care & Medicaid Services now does with quality-indicatorcompliance may prove to be the most effective means of pro-moting the patient safety movement within medicine.

Financial Disclosures: None reported.Disclaimer: Dr Livingston, a JAMA Contributing Editor, was not involved in theeditorial review of or decision to publish this article.

REFERENCES

1. IOM Committee on Quality of Health Care in America. To Err Is Human: Build-ing a Safer Health System. Washington, DC: National Academy Press; 2000.2. Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned?JAMA. 2005;293(19):2384-2390.3. Pronovost PJ, Faden RR. Setting priorities for patient safety: ethics, account-ability, and public engagement. JAMA. 2009;302(8):890-891.4. Wachter RM, Pronovost PJ. Balancing “no blame” with accountability in pa-tient safety. N Engl J Med. 2009;361(14):1401-1406.5. Blankstein A. Quaids settle with hospital. Los Angeles Times. December 16,2008.6. Zarembo A. Cedars-Sinai radiation overdoses went unseen at several points.Los Angeles Times. October 14, 2009.7. Letter to CEO of Rhode Island Hospital from the Rhode Island Department ofHealth (November 2, 2009). http://www.health.ri.gov/discipline/hospitals/RhodeIsland200911.pdf. Accessed December 4, 2009.8. Bush RL, DePalma RG, Itani KM, Henderson WG, Smith TS, Gunnar WP. Out-comes of care of abdominal aortic aneurysm in Veterans Health Administrationfacilities: results from the National Surgical Quality Improvement Program. Am JSurg. 2009;198(5)(suppl):S41-S48.9. Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and out-side of the operating room. Arch Surg. 2009;144(11):1028-1034.10. Sax HC, Browne P, Mayewski RJ, et al. Can aviation-based team training elicitsustainable behavioral change? Arch Surg. 2009;144(12):1133-1137.

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©2010 American Medical Association. All rights reserved. (Reprinted) JAMA, January 13, 2010—Vol 303, No. 2 161