> > The recent progress made in improving safety in airline travel,
is mostly due to better communication and equality
between the pilot and the copilot.
This wasn't always the case.
On January 13th, 1982, in Washington, D.C. Air Florida,
Flight 90 was preparing to depart.
While the copilot repeatedly expressed concerns about icy wings,
the pilot ignored seven different admonitions.
The plane went down in the icy Potomac River.
The National Transportation Safety Board conducted a post-crash study
and found that the airline industry had an exceedingly hierarchical
culture, in which many pilots did not value what copilots had to say,
and thus, they ignored them.
In medicine, we also have a hierarchical system
that needs to change.
This module will explore how we can improve and understand the science
of safety, by understanding how each system is designed
to achieve exactly the results that it gets.
System level factors that impact patient safety include
characteristics of the patient, of the provider, of the care team
and the work environment, and also institutional and external pressures.
As highlighted in the aviation example,
team level characteristics seem to be critically important.
In healthcare, the majority of sentinel events,
those events that cause significant harm to patients,
occur because of communication errors.
All of these factors can either defend against,
or put patients at risk.
A careful and honest review of these factors will enhance patient safety.
> > Teams from Michigan Hospitals were some of the first to implement CUSP.
> > Mary Jo: We were offered to participate in the CUSP Project,
and we had done a safety attitude questionnaire
and we had a department, the surgical department that fell
to the bottom of the list of the report, as far as their
safety culture. And we felt this was the perfect opportunity to
start with this particular department, so we talked to our leadership,
budgets weren't that great, they were very reluctant
to start a new project, but when we showed them the evidence
and the scores, and we were so excited, and we brought them over,
and they enabled us to join the project
and we're very glad that we did.
> > Chuck: A couple of things that we look
at from an administrative standpoint, is really cost, access and quality.
And you know, quality is very important to us,
and the patient's safety, but you have to balance
that with how much it costs you as well, as an organization.
And so some of the things that we were struggling with at the time,
like, many hospitals, we were in a deficit spending mode,
we were losing a little bit of money at the time, so you start looking
at staffing and trying to reduce your expenses
which are also very important to us, but then you also have to look
at how do you benefit the patient,
how do you create a safer environment,
and from an administrative standpoint,
if we can provide safer care, it's better care, and hopefully, in
the long run, it actually costs organizations and
really the federal government less money on healthcare
if we can provide better care.
> > Mary Jo: Some of the environmental issues that
we faced, were some staffing issues.
We had some traffic control issues, as far as how
people entered and left the departments.
One issue was, we had an open hallway right off the recovery room,
where staff just got used to going through there for their breaks,
which was an infection control, a privacy issue,
a lot of safety issues with that.
> > Peter: As we have heard from my friends in Michigan,
examining the characteristics of your system is the first step
to understand the factors that put your patients at risk.
Just as aviation elevated the copilot's role in the cockpit,
we need to elevate the concerns of the entire care team,
and the patients and their families, to a higher level.
In the next section, we will examine some
of the basic principles of safe design.