Ebola: what medicine can learn from Aviation Safety

Brian Hennessy, Blue Hawk Aviation, LLC

To professional airline pilots and other aviation industry professionals, the fact that our public and private health system dropped the ball by mishandling the introduction of Ebola into the United States should not come as a surprise. Nor should there be any surprise at medicine’s initial focus on placing blame on individuals (specifically nurses) rather than where it really lies: with a broken system and dysfunctional culture which does not yet recognize that human error is inevitable and therefore must be accounted for by a comprehensive safety system.  Over many decades aviation has developed just such a system; one that allows for, recognizes and “traps” human errors before they can lead to catastrophic failures.

Modern major airlines have a collective safety record that is, simply put, without peer. They belong to a unique class of industries termed “high reliability” — those that are inherently dangerous and where mishaps will likely involve large numbers of fatalities and/or injuries.  Yet the major airlines fly tens of thousands of flights per day without incident.  Consider the “natural state” of aviation: the natural thing for airplanes to do is to fly into the ground.  Gravity will take over when errors occur and are allowed to propagate unchecked.  Other high reliability industries include nuclear power generation, large scale chemical production, certain military functions, manufacturing and medicine.

Not too long ago commercial air travel was infinitely more dangerous than it is today. According to National Transportation Safety Board (NTSB) statistics, in the 1960s and 1970s commercial airplane crashes were an almost monthly occurrence, killing many hundreds of travelers per year.  By the early to mid-1980’s fatal commercial aircraft mishaps had fallen to approximately one per quarter, but were still killing over 200 people annually on average.  Flash forward to 2013 (the latest full year data available from the NTSB) and there was only one fatal accident (not even a crash) among major air carriers, resulting in only two fatalities.  When charted, this decrease in accidents and fatal mishaps has been consistent and is clearly not by chance, repeating year over year and decade over decade from the mid-1950s to the present.

Conversely, according to a ground breaking US Government study in 2000, the medical system in the United States consistently kills between 45,000 and 98,000 people annually through preventable human error. Compare this to the commercial aviation industry, where no one has died due to preventable human error on a major US airline (a “Flag” carrier) in many years.  To be sure, there are differences between aviation and medicine.  People present themselves to the medical system sick, and some sick people will die.  However, these aren’t the people represented in the appalling numbers above, which only counts those people who have died prematurely due to an otherwise preventable error made by a medical professional.  The Dallas Ebola case brings this problem into sharp focus.  Mr. Duncan may well have died of Ebola eventually, but as the response in New York has shown, he would have had a much better chance of surviving if he hadn’t been turned away on his first visit to the emergency room, despite being symptomatic for Ebola and indicating that he had visited an affected area.  This information was collected, recorded and available, but due to human error, was not used by a decision maker.  Nor would the two nurses in Dallas have gotten sick in all likelihood, had well established protocols been followed.

As the Dallas Ebola response shows us, nurses frequently get blamed for errors, but in truth doctors, the culture they operate in and the medical system in general are often much more to blame for preventable deaths. It also highlights a common problem in industries and activities lacking a robust and mature safety culture – a focus on “who” is to blame, rather than how the system failed to prevent the undesirable outcome in question.  Except in very rare cases of intentional or willful violations, aviation safety culture long ago moved away from blaming individuals, focusing instead on investigating and learning from errors, and further developing the safety systems and culture designed to trap them.

Doctors today operate in the same type of culture that commercial airline pilots did 50 years ago. Airline captains of this time frame tended to be unwilling to accept crew member input, made decisions in a vacuum, viewed themselves as the single most important “link in the chain”, were unwilling to embrace new thinking and standardization and were quick to deflect and assign blame for mistakes.  Fortunately, in commercial aviation this culture has changed completely to one that now embraces standardization, policies, procedures and technology as a way to control and trap the inevitable errors humans will make.  This change certainly did not take place overnight and in many cases significant change was prompted only after safety investigations resulting from significant loss of life.  It also requires constant vigilance by all parties involved and a 100% commitment to safe operations.  Based on over 5100 daily departures, If United Airlines, its pilots, mechanics and other employees were satisfied with a 99.9% safety record, the company would crash over 1,800 airplanes per year.

The good news is that medicine can leap forward decades by leveraging the hard and successful work of other high reliability industries, like aviation. Doctors must begin to look at the practice of medicine not wholly as an art, but rather as an inherently dangerous industry that can benefit greatly from policies, procedures, standardization training and technologies designed to account for and trap the errors that humans inevitably will make.  Only then can the medicine begin to develop a true safety culture and like commercial aviation, set the bar on preventable human error related deaths where it belongs, at zero.

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