Monday, May 23, 2011

One way to handle a near miss

The Blue Angels, the Navy's elite aerobatic team, have cancelled their annual performance at the Naval Academy's Commissioning Week. Why? Well, they had a near miss during a recent show:

"There was a deviation from the standard flight parameters during the show,” Kelly said.

The performance was halted and the Navy decided the team needed to head back to Pensacola for training and practice.

Let's think about the difference between this and the usual practice in hospitals. A near miss occurs. Most times, no one notices. Many times, no one says a word, even if the event is noticed. Some times, someone says something, and nothing happens. Still fewer times, someone says somethings and reports it up the chain of command, and nothing happens. Fewer times still, after it is reported up the chain of command, a root cause analysis is done. Fewer times still, after the root cause analysis is done, a change in protocol is designed and tested, and, if effective, training is carried out and implementation of the new protocol spreads through the organization.

For every reported adverse event in a hospital there are at least an order of magnitude, and perhaps two or three orders of magnitude, more unreported events. For every unreported event, there is a similar order of magnitude difference in the number of near misses.

Imagine if we had a standard of care in hospitals equal to that of the Blue Angels.

Nah, it can't be worth it. After all, they have six people to worry about, so many more than go to hospitals.

And the consequences of errors in hospitals are so insignificant.

Nah, it can't be worth it. After all, these things happen.


apthorpe said...

Impolitic as it is to mention 'nuclear' and 'safety' these days, the US nuclear industry knew it was vital to build a culture which accepts that problems will be found & fixed without killing the messenger. It's not perfect (nothing is) but compared to what I've seen in other industries, the nuclear people tend to be far more likely to take action before having the regulator take a stick to them and are less likely to throw employees under the bus. Yes, part of that stems from fear of the NRC but for the most part it's an accepted cost of operating a plant.

Some industries take root cause analysis to heart and find that it's cheaper/more profitable in the long run to find & fix small problems ASAP than drive them underground & drive off conscientious employees. Petty, short-term least-cost thinking and insecure management are some of the biggest problems; not sure there's a solution to that other than a regulator with a big stick.

Anonymous said...

Six people (well, they do have two 2-seater F/A-18s), but they each are flying a $30-60 million airplane.

I get your point, but that is not really a valid comparison.

Paul Levy said...

Dear apthorpe,

I think that is because the nuclear industry started in the Navy, in submarines. There, the culture was (and is) as you describe: An absolute acceptance and expectation that "call-outs" by any member of the crew were to be taken seriously and acted upon; and that corrective measures in one submarine would be disseminated throughout the service.

Dear Anon,

Add up the cost of the tens of thousands of people killed and maimed in American (and other countries') hospitals due to preventible errors. Please let me know if you think the comparison is really so off point.

Anonymous said...

An alternate take, and I would say, not so fast.

Depends where you look on the airplane:


@Lean_CEO Kevin Meyer said...

From Twitter:

Since we started to discuss safety as agenda #1 in our morning standups we've noticed new patterns and issues with near misses.

Paul Levy said...

Tah dah! Sometimes a small change in daily practice starts to make the cultural shift happen.

Anonymous said...

If one takes this analogy to its logical conclusion, then all surgeries in a hospital should be cancelled after an error or near miss until the root cause analysis is done so no one else is put at risk. I guarantee you that would get the physicians' and administrators' attention and spur change in a hurry.

Considering root cause analyses, if performed at all, often take months, this policy would imbue a long-absent sense of urgency about errors.

Nonlocal MD

Barry Carol said...

I’ve said before that to make patient safety a core priority and a cultural imperative requires leadership from the top to start. In this context, leadership includes making it clear that arrogant behavior by doctors, whether hospital employees or not, will not be tolerated. That includes threats of retribution against nurses and techs who try to speak up when they notice something wrong. When issues are raised, they need to be logged in and evaluated and the ultimate course of action or lack thereof needs to be communicated back to the person or people who raised the issue in the first place. If this approach includes some short term financial business risk for hospitals, so be it. It comes with the territory.

Marcus Hardy - CooperKatz for Physicians Foundation said...

As a long-time follower and fan of the Blues, I have come to admire and respect their uncanny precision, daring, caution and professionalism. Theirs is an apt model to strive for--thanks Paul for the excellent analogy. If I may expound a bit from my point of view:

The F/A-18 airframe that the Blues fly is a complex machine — and a hospital is similar — there are millions of moving parts and incredible intricacies in both things. For every flight hour of an F/A-18, there may be hours of maintenance and preparation completed in advance. If something goes wrong with that aircraft, life altering consequences come in to play. In a hospital's case, let’s think of flight time as surgeries or overall patient care and not forget the importance and bearing solid preparation will have on the organization.

Would that any organization that dealt in life/death adhered to the strict standards of the Blues.

Plus this all appeals to the airplane geek inside me, so what can I say?

Tom said...

The only difference between a near miss and an adverse event is CHANCE!!!! I spent along time trying to get our board to understand this simple concept and report data such as "falls" instead of just "injuries from falls."

Anonymous said...

The references to nuclear power, submarines and the U.S. Navy reminded me of "Doing a Job" (, a speech given by the Father of the Nuclear Navy, Admiral Hyman Rickover. Check it out.

Hadley Ford said...

Dear Paul,

Now that’s what I’m talking about! Lean and Six Sigma! Kaizan! Basic business principals to improve quality and drive down price. Did you know that before this simple concept enjoyed wide adoption (at least with Motorola, Toyota and the Blue Angels) that people actually thought quality would cost extra money? You really need to give me a call (you may find my number in my response to your open letter to CMS re proton therapy.) We would have a ton to talk about here. Why is healthcare the only industry where investment drives up prices? Why does everyone shrug and defend the status quo as it relates to process improvement in hospitals? This must be changed if we are ever to break the cost curve in healthcare and deliver higher value to our patients.

I couldn’t agree with you more.

Best regards,

Hadley Ford
ProCure Treatment Centers

Bruce said...

From Facebook:

When we work together in patient centered teams build around definable patient groups, then we will behave like the blue angels. As long as we function as individual physicians and in traditional hospital vertical department silos, nothing will change.

Anonymous said...

Dear Mr. Ford;

I'm not sure what your point is from the perspective of your position as CEO of a proton radiotherapy company, but I assure you if you go back and read Paul Levy's blog over the past 5 years, you would learn all you need to know about those subjects. There are no shortcuts.

nonlocal MD

Lucien Engelen said...

Dear Paul,

Once again thank you for your great vision and also courage to make things simple. Being responsible for out Trauma-helicopter the approach of the Blue Angels looks "familiar", even so the analogy with the other system we're in.
It is a though battle, winning step-by-step, we think we are on the right track.

Your blogpost (will spread in house) will help us again, to toss in a different approach, perspective and ... chance to do even better tomorrow than we do today.

Thank you for that.

tomp said...

Big motivator for the Blue Angels is pilot errors kill pilots; think who is first at the crash site? The pilot.

Hospital errors do not kill the "pilots"-Food for thought?

Anonymous said...

tomp, I commented on this phenomenon on one of Paul's posts a year or 2 ago, where an aviation expert who had been consulted on medical issues remarked, somewhat cavalierly, that pilots did not have a group such as MITSS to support pilots involved in errors.
The obvious reason is that the pilots were also the victims. However, we still see pilots do stupid things, don't we?
In addition, I don't think the Blue Angels wanted to risk crashing a plane into the thousands of spectators, so it's not pure self interest.