There are constant comparisons between aviation and healthcare especially in terms of how safe aviation is. There is no doubt that aviation in general has a low mortality rate for passengers. I have already written about the need to learn from how aviation achieved it, I have also pointed out to the limitations of the comparisons (http://successinhealthcare.blogspot.co.uk/2012/04/healthcare-not-similar-to-aviation-but.html). The term aviation or air transport in my view, includes many things, which starts from the booking process, airport formalities, baggage, catering, flying, etc. It also includes transportation of animals and goods.
In general, the whole of aviation is considered arguably to be better than healthcare. What is not arguable is that commercial scheduled airlines have a very low mortality rate for passengers. Here is my problem, death is not one of the eventual natural outcomes of transportation when transporting essentially healthy persons from one place to another; quite rightly in aviation is mortality is unacceptable. Hospitals on the other hand are not in the business of transporting passengers, people come in with illnesses and diseases many of which are really serious; mortality is one of the eventual outcomes of serious illness and disease. In other words healthcare routinely battles against death and sometimes death wins.
To compare error rates could be valid as error is often a measurable part of process failure but to compare the impact of those errors is probably a false comparison. In aviation all mortality is avoidable mortality, in healthcare it is not. So to put it in context the comparison if we must is between all mortality in aviation and avoidable mortality in healthcare (i.e. the result of process failure). That is what I mean by impact. The impact of errors that result 'morbidity' is of course hugely different like losing a bag vs losing a leg. Hence let us not compare impacts of errors such as mortality morbidity between aviation and healthcare which skews the public discourse. Let us look at error rates and see what we can learn.
To compare error rates could be valid as error is often a measurable part of process failure but to compare the impact of those errors is probably a false comparison. In aviation all mortality is avoidable mortality, in healthcare it is not. So to put it in context the comparison if we must is between all mortality in aviation and avoidable mortality in healthcare (i.e. the result of process failure). That is what I mean by impact. The impact of errors that result 'morbidity' is of course hugely different like losing a bag vs losing a leg. Hence let us not compare impacts of errors such as mortality morbidity between aviation and healthcare which skews the public discourse. Let us look at error rates and see what we can learn.
Variation the enemy of quality
People talk about
variation of care across hospitals and locations; it is true that
there is wide variation and reducing the variation will improve
outcomes.
Aviation which is often
looked upon as a beacon of safety also has variation. Looking at 2004
accident rates for North American airlines Delta scored 0.30 and
Value Jet/Air Tran scored 5.88 – well, you work out the how wide
the variation is even in an ultra safe industry. If you start looking
at international comparisons the variations are of course much worse.
(http://www.airdisaster.com/statistics/)
There is also a five times variation of fatalilties per million
flight hours with scheduled airlines being lowest compared with
general aviation.
When there is human to
machine interaction as in aviation, there is such a large degree of variation.
Healthcare is human to human interaction so it is hardly surprising
that variation exists and could be expected to be more than other
industries. Looks like variation in performance is not a problem
exclusive to healthcare industry; variation is a human problem or to
put it better, variation is a function of human performance.
That does not mean we must accept variation especially when it causes harm, we should work very hard to reduce it to ensure safe healthcare.
That does not mean we must accept variation especially when it causes harm, we should work very hard to reduce it to ensure safe healthcare.
Fatalities in Aviation
The human fatality rate
is very low indeed in the scheduled airlines part of the aviation
industry. The air transport of animals, however has suffered bad
press. Airlines are apparently not even required to report animal
deaths. The mortality rate of animals in air transport is thought to
be 0.2%.(http://www.dailymail.co.uk/news/article-2102733/More-HALF-pets-died-airline-travel-year-flew-Delta.html)
The post surgical 30
day mortality for day case surgery in humans which is about 0.01%.
In-hospital mortality for day cases is probably as low as the
scheduled commercial aviation segment.
CRM and Simulation are of
course extremely valuable tools and has a lot to teach us in healthcare. The number
of air accidents and the number of fatal air accidents have
remarkably decreased over the past few decades. That is truly
fantastic. What is interesting though, is that the pilot error rate
has been at about 50% since the 1950s to the 2000s, percentage of
accidents attributed to pilot errors has not shown a significant
decrease. The proportions of various reasons for crashes have also
remained more or less the same. This is in a way a tribute to the
aviation industry, since the planes have become technologically very
superior it would not be surprising if pilot/human error
played a bigger part and it has not, that is creditable. However, I wonder if it would be valid to argue that if CRM and simulation were indeed really powerful should the pilot error rates be falling?
Survival rates of
passengers in aircrafts involved in fatal accidents has not improved
(and averages about 25% since the 1930s to 2000s)
(http://planecrashinfo.com/cause.htm)
Military aircraft, fighter planes, aircraft engaged in warfare and
private planes are thought to have much higher accident and fatality
rate.
Some Aspects of Aviation are Safer than Others; Some Aspects of Healthcare are Safer than Others
I suppose in clinical
healthcare delivery terms, scheduled airlines are possibly the equivalent of out
patient care – not many patients die in out patient clinics. The risk to life is also very low for elective investigations, day case
surgery and obviously the risk increases with emergencies and trauma.
In healthcare we talk about morbidity as well. Airlines perhaps should take into consideration DVTs, respiratory illnesses, musculo-skeletal problems and other health issues that happen after a flight. Non-health related morbidity for aviation perhaps include lost baggage, wrong meals............... no let me stop there before it gets silly. Hold on, why not, non-flying errors are also errors and results in 'airline industry morbidity' to passengers, perhaps not that silly.
What has to be said is in healthcare there is clearly much avoidable mortality - that is unacceptable. In healthcare the error rates in day to day activities are simply too high, that is again unacceptable. That is where learning meaningfully from other industries will help.
What has to be said is in healthcare there is clearly much avoidable mortality - that is unacceptable. In healthcare the error rates in day to day activities are simply too high, that is again unacceptable. That is where learning meaningfully from other industries will help.
There is a fundamental
problem with my writing here. I am not comparing like for like, I am
comparing apples to pears. In my defense, I did not start that
comparison. Comparing aviation to healthcare was not my original
idea. There is a second problem with this manner of writing, it may
sound like I am being defensive of healthcare and its practices, I am
certainly not defending any poor healthcare practice or result. I
acknowledge the superior results that aviation has had as a result of
dedicated persistent efforts in the field of human transportation in
scheduled airlines. I recognise the need for healthcare to learn from
every source possible including commercial scheduled airlines. All I
am saying is, let us stop comparisons and let us focus on learning.
Let us look for clinical adaptations of these techniques rather than
attempted direct transfer of airline techniques. Let us recognise the uniqueness and the
intimacy of human to human interaction that healthcare involves.
A word of warning: This is not a 'hate aviation' piece of writing, this is not aviation versus healthcare writing. This is a plea to learn the lessons in a way that is appropriate to healthcare - clinicians and patients.
A word of warning: This is not a 'hate aviation' piece of writing, this is not aviation versus healthcare writing. This is a plea to learn the lessons in a way that is appropriate to healthcare - clinicians and patients.
©M HEMADRI
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