This is a blog by a former CEO of a large Boston hospital to share thoughts about hospitals, medicine, and health care issues.
As a fellow geek I of course recognize the comedy in this situation. But let's not forget that RIGID, THOU SHALT NOT VIOLATE rules like "Thou SHALT deliver the paper trail about X, Y and Z is delivered"... those rules were part of the STANDARD WORK we developed to make airlines safer. We may ridicule the lack of a backup process but every time I hear of another death from medical error, AND every time my flight is delayed due to safety policies, I think of the bottom line *success* of the procedures developed in the airline industry - and lacking in medicine.So sure, we can grin, but let's not forget why this is being done. And let's not humiliate them to the point where they back off from what's *really* important.
e-Patient Dave is right. Flight procedures are strictly followed by passenger airlines for a good reason. This story also indicates that they had alternative paths to deal with in process failures. It may be a little annoying, but these procedures have shown their value. From time to time I read the NTSB crash reports at http://www.ntsb.gov/investigations/reports_aviation.html for reminders of how to do a good after action report. They usually identify multiple safety issues, multiple causes, and have multiple recommendations for improvement. They generally avoid the blame game. This kind of failure analysis is something for healthcare to strive for.Air crashes are sufficiently different and sufficiently interesting that they make good material for education. Other reports can be interesting, but much too often they are of the form: "Ship sank due to flooding in engine room. Cause unknown. Crew, support, and rescue operations were ..." with no problems identified or recommendations to make.The aviation obsession with documenting every last detail also preserves information needed to understand the occasional failures.
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