The Airline Industry and Patient Safety

Air traffic controllers' errors and Patient Safety:

According to the Associated Press, reports of errors by federal air traffic controllers have doubled last year! Citing the Federal Aviation Administration's official tally, the report says there were 1,889 operation errors in the 12 months ending on Sept. 30, 2010 vs. 947 a year earlier. During the same period in 2009, there were 1008 errors. The FAA says the higher number of reported errors - which usually mean aircraft coming too close together - is due to better reporting and improved technology that can determine more precisely how close planes are in the air. Few of the errors fall into the most serious category, which could result in pilots taking action to prevent an accident, AP says. In the year ending Sept. 30, there were 44 such events vs. 37 in the prior year. At a hearing before the House aviation subcommittee earlier this week, FAA Administrator Randy Babbitt was asked about the rise in error reports. He states that the FAA is seeing more errors partly because a safety program, introduced in 2008, protects controllers from punishment for errors they voluntarily report. The program is receiving about 250 reports a week. Unfortunately, the medical industry does NOT pursue the same error prevention strategy. In the 10 years since publication of the Institute of Medicine’s report “To Err is Human,” extensive efforts have been undertaken to improve patient safety. The question remains: did they succeed? Yes, we are talking about the need for patient safety and physicians have to attend mandated medical error prevention courses. But did we change anything? According to a recent study of 10 North Carolina hospitals published in the New England Journal of Medicine[1], the authors found that harm remain common, with little evidence for widespread improvement. Prescribing errors occurred in 7.6% of outpatient prescriptions and many could have harmed patients.[2] Prescription-error related malpractice lawsuits are the second most frequent and the second most expensive types of suits filed against physicians. But practicing physicians in outpatient settings still do not have access to medical error databases representing the aggregation of voluntary incident reports. The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) authorized the creation of PSOs to improve quality and safety by reducing the incidence of events that adversely affect patients but many of those PSO still are not open for incident reporting by primary care physicians in private practice. In 2006, outpatient visits accounted for $850 billion, making it more than 41% of our health care spending but most medical errors occurring in this setting are NOT being reported or registered. Subsequently, billions of dollars are being wasted and thousands of lives are lost every year. So what can we learn from the airline industry? That we should create the FAA equivalent of a Patient Safety Organization authorized to collect ALL medical error incidents which then can be used to educate and guide physician in error prevention strategies. I ask myself why the medical industry and physicians are opposing such a strategy? Our patients deserve an answer!

[1] http://www.nejm.org/doi/full/10.1056/NEJMsa1004404

[2] http://science.icmcc.org/2010/08/26/outpatient-prescribing-errors-and-the-impact-of-computerized-prescribing/