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Come Fly With Me: Safety and HumanFactors: Bringing Aviation into the

Operating RoomBarbara G. Jericho, MD

Department of Anesthesiology

University of Illinois Hospital and Health Sciences System

Chicago, Illinois

Learning Objectives:As a result of completing this activity, the participantwill be able to Describe the similarities and differences between

aviation and health care

Explain the safety methods and tools used in theaviation industry

Describe how health care can utilize the aviationindustrys safety methods and tools to improvepatient safety

Summarize existing healthcare patient safety ini-tiatives and their roles in patient safety

Author Disclosure Information:Dr. Jericho has disclosed that she has no financialinterests in or significant relationship with anycommercial companies pertaining to this educationalactivity.

In 1995, Flight 965 crashed into a mountain in Colombiaand eight crew members and 152 passengers died.1 Thiscrash was one of many controlled flight into terrain

accidents that stimulated the US government to collabo-

rate with the aviation industry to reduce the risks ofaviation accidents. In February 1997, the White HouseCommission on Aviation Safety and Security challenged thegovernment and the aviation industry to reduce the aviationaccident rate by 80% over 10 years.2 Furthermore, theNational Civil Aviation Review Commission recommendedthat the industry andgovernment, represented by the FederalAviation Administration (FAA), collaborate to develop,implement, and assess the progress of an aviation safetyplan.2 As a result, the Commercial Aviation Safety Team(CAST) was formed in 1998.2 The diverse members ofCAST include manufacturers, airlines, labor organizations,the Flight Safety Foundation (an international organization),and governmental agencies such as the FAA, NationalAeronautics and Space Administration (NASA), the Euro-pean Aviation Safety Agency/Joint Aviation Authority, andthe US Department of Defense.3 Indeed, in a report from

June 2010, the fatality risk for commercial aviation in the

United States was reduced by 83% in the 10-year periodfrom 1998 to 2008.4 CAST plans to further reduce thisfatality risk at least 50% from 2010 to 2025.5

Aviation has achieved a sought-after record of safety.However, the risk of mortality in health care, another high-hazard industry, exceeds the fatality risk of aviation, andthis figure is not decreasing. The FAA reported that therewere 0.4, 6.7, 0.3, and 0.0 commercial aviation fatalitiesper 100 million persons on board in the years 2008, 2009,2010, and 2011, respectively.6 In contrast, the Institute ofMedicine in 1999 reported that up to 100,000 patientsdied annually in the United States because of preventableadverse events.7 Ten years later, there does not seem to be an

65

Supplemental digital content is available for this article. Direct URLcitations appear in the printed text and are available in both the HTMLand PDF versions of this article. Links to the digital files are provided inthe HTML and PDF text of this article on the Journals Web site(www.asa-refresher.com).

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improvement in these figures. The HealthGrades PatientSafety in American Hospitals Study reported in 2009 thatnearly 100,000 Medicare patients alone died because ofpreventable in-hospital medical errors.8 Medication errors,wrong-site surgery, foreign bodies retained in patients,equipment failure, transfusion errors, and infections continue

to be reported9 (Supplemental Digital Content 1, http://links.lww.com/ASA/A136, Supplemental Digital Content 2, http://links.lww.com/ASA/A137, and Supplemental Digital Con-tent 3, http://links.lww.com/ASA/A138).

The HealthGrades Patient Safety in American

Hospitals Study reported in 2009 that nearly

100,000 Medicare patients alone died

because of preventable in-hospital

medical errors.

Although the safety records may differ, aviation andhealth care share a common factor in the root cause ofthese adverse events: human factors. Human factors, incontrast to environmental or equipment causes, constitutethe most common cause of aviation accidents.10 Similarly,human factors were the most frequently identified rootcauses of healthcare sentinel events in 2011 as reported bythe Joint Commission11 (Supplemental Digital Content 4,http://links.lww.com/ASA/A139 ). Specifically in the prac-tice of anesthesia, Cooper et al.12 found that 82% of pre-ventable errors involved human error (SupplementalDigital Content 5, http://links.lww.com/ASA/A140 ). Sex-ton and colleagues compared human factors of attituderegarding error, stress, and teamwork of operating roomand intensive care unit (ICU) physicians, nurses, fellows,and residents with those of captains and first and secondofficers from airlines around the world. They found thathealthcare workers were more likely than pilots to denythe effects of fatigue on performance; that surgeons weremore likely to deny the effects of personal problems ontheir work compared with pilots, anesthesia staff, andnurses; and that the majority of pilots and medical per-sonnel felt that their decision-making was as good inemergent as in nonemergent situations.13 Also, with regard

to teamwork, surgeons perceived teamwork and commu-nication to be of a higher quality compared with the per-ception of the rest of the medical team.13 Furthermore, inthe ICUs, physicians rated teamwork with nurses to bebetter than nurses rated teamwork with physicians.13 Inthe same study, trained observers ratings of success ofteamwork were greater in aviation than in surgery, anes-thesia, and between surgery and anesthesia.13 With regardto the chain of command, Sexton et al.13 found that themajority of pilots, anesthesia staff, and ICU staff, but notsurgeons, felt that junior members should question thedecisions of senior team members. Thus, the safety of thepractice environment in both aviation and health care is

affected by human factors. Members of both professionsmay feel that their decision-making is adequate in bothemergent and nonemergent situations; yet, the recognitionof the effects of fatigue and a greater display of teamworkwere present more in aviation professionals than in thosein health care.

Although safety records may differ, aviation

and health care share a common factor in the

root cause of these adverse events: human

factors.

As aviation and health care are both high-hazard in-dustries that share a common factor in the root cause ofsafety events, one may wonder whether the safety methodsand tools of the aviation industry can be applied to health

care with similar safety results. This chapter describessafety methods and tools used in the aviation industry thathealth care can implement in a standardized manner toimprove patient safety and employ process improvementswithin healthcare systems.

CREW RESOURCE MANAGEMENT

Aviation and CRMAfter a fatal crash involving repeated unsuccessful at-tempts by the second officer to notify the captain that theaircraft had insufficient fuel, the National TransportationSafety Board in 1979 called for a method of crew resourcemanagement (CRM) to address training in assertiveness.14

CRM instructs on the use of checklists, effective commu-nication, and assertiveness to clearly articulate discrep-ancies between what should be and what is actuallyoccurring. Originally known as cockpit resource manage-ment, this training was extended to include other aviationteam members such as flight dispatchers, cabin crews, andmaintenance personnel, and thus became known as CRM.The first comprehensive CRM program in the UnitedStates was started in 1981.14

Helmreich and Foushee15 define CRM as optimizingnot only the person-machine interface and the acquisition

of timely, appropriate information, but also interpersonalactivities including leadership, effective team formationand maintenance, problem-solving, decision-making, andmaintaining situation awareness. CRM eventually be-came part of the annual training for crew members andincluded classroom instruction as well as Line-OrientedFlight training, a simulation-based training program.15

Line-Oriented Flight Training includes team communica-tion before and after the flight simulator and the assess-ment of crew performance.16

Helmreich et al.17 stated that as there are very few acci-dents and as there is no specific, standardized CRM train-ing program across all airlines for a uniform comparison,

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it would be difficult to validate the effectiveness of CRM inaviation safety. To evaluate CRM in another manner, Salaset al.18 identified and reviewed 58 studies that appraisedthe effectiveness of aviation CRM training programs. Usingfour levels of training evaluation identified by Kirkpatrick(reactions, learning, behavior, and results of organizational

effectiveness),19 Salas et al.18 described how CRM trainingfits in that framework (Table 1). Although as Helmreichet al.,17 stated, Sala et al.,18 also found no evidence forthe effectiveness of CRM training on aviation safety(organizational effectiveness).

Health Care and CRMThe Institute of Medicine report discussed the contributionof human factors to patient safety.7 In the year 2000, theInstitute of Medicine recommended using CRM, because ofits success in aviation, to train personnel in critical care di-visions.7 Specifically, the Institute of Medicine believes that

health care organizations should establish team trainingprograms for personnel in critical care areas (e.g., theemergency department, ICU, and OR) using proven meth-ods such as CRM techniques employed in aviation, includ-ing simulation.7 The Joint Commission also recommendedteam training as a part of its national patient safety plan.20

Since then, CRM training has been adapted to clinicalenvironments with improvements in performance, atti-tude, and patient safety. Morey et al.21 evaluated the ap-plication of training derived from CRM to the emergencydepartment and showed that the clinical error rate de-creased significantly from 31% to 4% with improvements

in team behavior, performance, and attitude and opinionstoward teamwork. Furthermore, Awad et al.22 showedthat CRM training of surgical service staff in the operatingroom improved communication and patient safety. Withthe use of preoperative briefings, as shown by Awadet al.,22 the number of patients who received prophylactic

antibiotics 1 h before incision and the number of patientswho received deep venous thrombosis prophylaxis beforeinduction increased significantly.

In summary, aviation CRM training can be adapted toclinical environments with improvements in performance,attitudes, and patient safety. However, unlike CRM inaviation, CRM is not a required part of annual trainingand is not widely adopted in all healthcare environmentsand organizations.23

INCIDENT REPORTING

AviationThe aviation industry has a national reporting system inplace to facilitate the reporting of events, identify sourcesand types of errors, analyze error trends, and provideproactive solutions to avoid fatal accidents. The aviationindustrys confidential, nonpunitive, voluntary reportingprograms such as the NASA Aviation Safety ReportingSystem, the collection and analysis of flight recorded datain the Flight Operational Quality Assurance Program, theVoluntary Disclosure Reporting Program, and the Ad-vanced Qualification Program permit the identification ofpotential safety issues and trends.24,25 Participants in theAviation Safety Reporting System include not only pilotsbut also mechanics, air traffic controllers, dispatchers,cabin crew, and ground crew.24 The FAA offers incentivesto event reporters, as the FAA will not use the con-fidentially reported information from Aviation Safety Re-porting System in enforcement actions and will waive finesand penalties for unintentional violations of FAA statutesand regulations with certain limitations.24 Reported data(personal names, organizational names, dates, and times)are deidentified and aggregated. The FAA uses the de-identified data to analyze trends with the goal to aim re-sources to rectify safety issues in the National AirspaceSystem, Air Traffic Control, and flight and airport oper-

ations.25

In addition, the Line Operations Safety Auditinvolves experts on airline flights observing and collectingdata from flight crew actions, situational factors, errorsand potential errors, and the management of errors by thecrew.26 These audits are nonpunitive; that is, flight crewsare not held responsible for their observed behaviors orerrors, and the data presented from Line Operations SafetyAudit are deidentified.26 Moreover, the Aviation SafetyInformation Analysis and Sharing Program, which is a partof the CAST process, links safety databases across theaviation industry allowing a global review of data fromair carriers and the identification of potential adverseevents and trends.4 In addition to voluntary, confidential

Table 1. Appraisal of the Effectiveness of Aviation

Crew Resource Management (CRM) Training18

Evidence of

CRM Training

Effect

Level of

Training

Evaluation*

Aviators like CRM training Reaction

Perceived to be beneficial to the

actions of aviators

Reaction

Leads to positive changes in attitudes Learning

Increased cognizance of human

factors, crew performance, potential

stressors, and the means to address

these stressors

Learning

Allowed individuals to display a greater

understanding of CRM principles

compared with individuals not

instructed in CRM

Learning

Demonstrated individual behavior

(primarily in a simulated environment)

that reflected knowledge learned in

CRM training

Behavior

Effectiveness of CRM training on

aviation safety

Organizational

effectiveness

*Four levels of training evaluation identified by Kirkpatrick (reactions, learning,

behavior, and results of organizational effectiveness).19

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reporting programs, specific events must be reported to theNational Transportation Safety Board.27

Health CareIn contrast to the established reporting system in the avi-ation industry, the reporting system in health care is not

well established, nor is it standardized. The communica-tion of deidentified data among national medical organ-izations and specialties is not practiced consistently. Inaddition, there are attitude and knowledge barriers tomedical reporting.

More than 10 years ago, the Institute of Medicine en-couraged healthcare organizations to implement voluntaryreporting systems so that factors contributing to medicalerrors could be better understood.7 As a result, medicalerror reporting systems are present in 27 states and in theDistrict of Columbia.28 Only 12 states require reporting ofnosocomial infections.28 However, the reporting of mostsentinel events or serious medical errors from individual

organizations or specialties to the Joint Commission, anational organization, continues to be voluntary.9 In fact,only 58% of sentinel events reported to the Joint Com-mission from 2004 to 2010 were self-reported.9

In 2005, the Patient Safety and Quality ImprovementAct was passed to encourage the reporting of patient safetyevents in a voluntary and confidential manner without fearof legal discovery.29 This act creates Patient Safety Or-ganizations (PSOs) and establishes the Network of PatientSafety Databases that analyze collected patient safety dataand identify trends of patient safety occurrences.29 Thefindings are reported each year in AHRQs NationalHealth Quality and Disparities Report. The AHRQ ex-ecutes the provisions of the Patient Safety and QualityImprovement Act addressing PSOs.30 However, the PSOdata do not encompass all errors in health care; for ex-ample, laboratory testing errors do not have a standardreporting system database.28 There are 77 PSOs in 31states and in the District of Columbia that are currentlylisted by AHRQ.31 PSOs are voluntary and are not feder-ally funded, and any public or private, for-profit or not-for-profit entity can be a PSO. However, health insuranceissuers, licensing bodies, and mandatory public reportingsystems cannot be PSOs.30 For example, the AnesthesiaQuality Institute is a PSO and was created by the American

Society of Anesthesiologists in 2008.32

To achieve the safety record of the aviation industry,incident reporting in health care may need to be centralizedand standardized. Furthermore, individuals involved inhealthcare-related organizations and institutions should beencouraged to report incidents in a confidential andnonpunitive reporting system. Once data are reported,deidentified data can be linked and analyzed to identifytrends and near misses. Finally, identified patient safetyissues can be communicated to achieve national processimprovements in health care.

Despite mandates and the presence of healthcare regu-latory organizations to address patient safety, barriers to

incident reporting still exist and include the fear of legalliability,31 fear of punitive action or shame and blame,33

lack of a safety culture within an institution, lack of ano-nymity,33 and lack of feedback to clinicians on whatchanges will be made on the basis of their reports.34 In asurvey by Garbutt and colleagues, over 80% of physicians

revealed that they would increase their formal reporting ofmedical errors in the event of the following: (1) they wereassured that the information would be kept confidential;(2) the reported medical errors would not be open to legaldiscovery and would not result in punitive action; and (3)there was evidence that ensured that changes in the systemwould be made on the basis of reported medical errors.35

They also showed that surveyed physicians would formallyreport more medical errors if the process took

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with evidence-based procedures, measured the outcomes,and demonstrated reductions in morbidity and mortalityas well as overall improvements in patient safety. Hart andOwen41 investigated the use of an aviation-style checklistfor the preparation of a cesarean section under generalanesthesia. The researchers found that, with memory

alone, important steps in the preparation of the case wereforgotten and hence most participants in the study felt thatthe checklist was useful.41 Furthermore, in a study by Be-renholtz et al.,42 a checklist was developed at John Hop-kins to help decrease the incidence of infections associatedwith central line insertion, with a reduction in infectionrate from 11% to zero over 1 year. Finally, Haynes et al.43

showed that, after implementing the 19-item World HealthOrganization surgical safety checklist in the operatingroom of eight hospitals around the world, postoperativecomplications and mortality decreased by 36% on averagein diverse clinical and economic environments. By suc-cessfully utilizing the World Health Organization Surgical

Safety Checklist across the world, at least 500,000 deathscould be prevented.44

Therefore, the utilization of checklists in aviation andhealth care has been shown to be successful in improvingboth patient and aviation safety. Unlike aviation, however,health care does not have a checklist to address the phys-ical and emotional state of the healthcare worker.

SIMULATION-BASED TRAINING

Simulation-based training allows individuals and teams topractice performing in situations representative of realconditions without actual injury to persons, review deci-sions and the results of their actions, and receive feedbackon responses to the simulated situation-based training.Simulation training is utilized in industries such as aviationas well as in health care and its diverse specialties includingsurgery, cardiology, radiology, and anesthesiology.4548

In the late 1980s, anesthesiology began using simulatorswith grant funding support from the Anesthesia PatientSafety Foundation.49 Subsequently, an anesthesia simu-lation-based curriculum based partly on the principlesof CRM called the Anesthesia Crisis Resource Manage-ment (ACRM) curriculum was developed and involvedsimulation scenarios and debriefing.50 ACRM has been

adopted at worldwide healthcare institutions and has beenutilized by other healthcare specialties. Ideally, to evaluatethe effectiveness of ACRM, patient outcomes from simu-lation-trained physicians would need to be compared withpatient outcomes from physicians who did not participatein simulation-based training.48 However, this study wouldnot be feasible to conduct as there are many variables toconsider, such as patient comorbidities and complications.Despite the difficulty in assessing the effectiveness ofACRM in this manner, some studies have honed their focuson the participants evaluation of their experiences and theimprovement in patient care during specific clinical eventsafter simulation-based training. In a study by Holzman

et al.,48 about 80% of anesthesiologists participating in anACRM training course revealed that they valued the ex-perience highly and felt the course would improve thesafety of their anesthesia practice. In a study by Wayneet al.,51 internal medicine residents who underwent simu-lation-based training in Advanced Cardiac Life Support

exhibited improvement in patient care by exhibiting agreater adherence to the American Heart Association Ad-vanced Cardiac Life Support guidelines compared withresidents who did not undergo simulation-based training.

Unlike most healthcare staff, airline pilots are requiredto participate in CRM and simulation-based training.23

Commercial pilots are simulation tested every 6 monthsfor certification in some skills and are tested each year in ahigh-fidelity team simulator.52 Similarly, the AmericanBoard of Anesthesiology has incorporated simulation asone of its Practice Performance Assessment and Improve-ment (Part IV) requirements for its Maintenance ofCertification in Anesthesiology process.53

Interestingly, simulation-based training in health care isnot only used for training and fulfilling mandatory re-quirements but is also considered in the malpractice pre-mium rates of Harvard-affiliated anesthesiologists. TheControlled Risk Insurance Company, the malpractice in-surance carrier for Harvard-affiliated physicians, rec-ommended in 2006 a 25% reduction in malpracticepremiums for anesthesiologists who have undergone sim-ulation training.54

REGULATION OF WORK HOURS

Sleep deprivation increases the risk of human error-relatedaccidents.55 In fact, Dawson and Reid56equated the de-cline in psychomotor function from sleep deprivation for24 hours to an unlawful blood alcohol level of0.10%. Assuggested by a meta-analysis by Philibert,57 physiciancognitive performance is negatively affected by sleep dep-rivation; furthermore, vigilance and clinical performanceare more affected by sleep deprivation than are memoryand cognitive function. Denisco et al.58 studied the effectof sleep deprivation of anesthesia residents on the per-formance of simulated critical tasks. The researchers foundthat those residents who were sleep deprived after a 24-hour call shift scored less well on the performance of tasks

than did those residents who were well rested.58

Concernsabout the negative effects of sleep deprivation and fatigueon resident education, patient safety, and personal well-being resulted in the limitation of resident duty hours in200359; yet, no duty hour limits exist for healthcare staffwho are no longer in training. Healthcare staff who havecompleted their training are still vulnerable to the personaland professional consequences of sleep deprivation andfatigue. Rothschild et al.,60 in a matched retrospective co-hort study, found that there was a significant increase incomplication rates, attributed to attending surgeons, ofpost-nighttime surgical cases in which the attending sur-geon had 6 hours or less of sleep compared with cases in

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which the attending surgeon had more than 6 hours ofsleep.

The potential hazardous effects of sleep deprivation arenot only recognized in health care but also have affectedthe safety of passengers in the airline industry. Since 1993,fatigue contributed to seven aviation accidents in the

United States, resulting in 250 fatalities.61 To address theconcerns of the effect of fatigue on airline accidents, airlinepilots work hours are regulated, unlike the work hours ofhealthcare staff that are no longer in training. Pilots cannotfly for more than 1,000 hours in a calendar year, 100 hoursin any calendar month, 30 hours in any 7 consecutive days,and must have 8-hour required rest periods.62

HEALTHCARE PATIENT SAFETY INITIATIVES

In addition to utilizing some of aviations safety tools,health care has implemented a number of initiatives inpatient safety at both public and private levels.

In 1985, the Anesthesia Patient Safety Foundation wasfounded by the American Society of Anesthesiologists witha mission of safety education, research and the awarding ofresearch grants, patient safety programs, and the exchangeof patient safety information nationally and internation-ally.63,64 The Anesthesia Patient Safety Foundation is anindependent, nonprofit organization comprising a diversegroup of board members including anesthesiologists, nurseanesthetists, nurses, manufacturers of equipment anddrugs, regulators, risk managers, attorneys, insurers, andengineers.63 Because of their efforts, by the mid 1990s, theinsurance risk relativity rating for anesthesiology com-pared with other medical specialties had been significantlyreduced.63 Furthermore, over the last 50 years there hasbeen a significant decrease in anesthesia-related deaths.65

Following the example of the Anesthesia Patient SafetyFoundation, in 1997 the American Medical Associationand partners established the National Patient SafetyFoundation.66 The National Patient Safety Foundation isan independent not-for-profit organization that sponsorspatient safety research and education, raises publicawareness, and promotes communication about patientsafety.67 The Lucian Leape Institute at the National PatientSafety Foundation was established in 2007 to identify newmethods to improve patient safety.68 Recent activities at

the Lucian Leape Institute include a report focusing on therestructuring of medical student education to addresssafety in order to strengthen and continue future im-provements in overall patient safety.68

In 1997, the Veterans Health Administration establishedthe National Patient Safety Partnership, a public-privatepartnership, that incorporates visions from the nationsexperts on patient safety.69 In 1999, the Veterans HealthAdministration created the National Center for PatientSafety to decrease adverse events and near misses, create asafety culture, and develop patient safety programs andinitiatives.70 Following the initiation of the program, theNational Center for Patient Safety had a 900-fold increase

in the reporting of near misses of serious events.70 TheNational Center for Patient Safety has executed and uti-lizes the Patient Safety Information System, the con-fidential, nonpunitive electronic reporting system at theVeterans Health Administration.70 Nearly 800,000 safetyreports have been recorded in the Patient Safety In-

formation System since 1999.71Finally, the Leapfrog Group was begun in the year 2000,

is driven by employers striving to purchase high-qualityhealth care for their employees, and recognizes hospitalswith strong safety records.72 This group focuses on fourleaps: Computer Physician Order Entry, Evidence-BasedHospital Referral, ICU Physician Staffing, and LeapfrogSafe Practices Score.73 Lwin and Shepard74state that if allhospitals implemented the first three of Leapfrogs fourleaps, or recommended quality and safety practices, over57,000 lives could be saved, more than three millionmedication errors could be avoided, and up to $12 billioncould be saved each year.

DIFFERENCES AND SIMILARITIES BETWEEN

AVIATION AND HEALTH CARE

Aviation and health care are similar in that both are high-hazard industries operating with technology. In both pro-fessions, safety is of considerable importance. The safetyrisk, however, in both professions is not consistent; it in-volves multiple changing variables and can vacillate from alow-risk to a high-risk situation.75 Regulations, legal con-cerns, and cost issues influence the practice of both of theseprofessions.75 Furthermore, teamwork and effective com-

munication are essential in these complex technologicalenvironments.75

Patient safety can be improved through a safe

means for people to report events, encourag-

ing reporting to identify areas of potential risk,

a well-established and standardized institu-

tional reporting system, a national system to

link deidentified data from error reporting

databases, identification of trends in reported

errors, national communication of findings,

and system-based process improvements in

health care and patient safety.

When aviation accidents occur, they are usually highlypublicized, involve loss of multiple lives at the same time,including the possible deaths of pilots and crew, and in-volve public reporting of the event after a standardizedinvestigation of the event.75 However, healthcare adverse

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events involve loss of individual patient lives, are in-frequently publicized, do not involve the death of health-care staff, and involve a nonstandard investigation andreporting of the event.75 Standardized reporting and in-vestigation of events may be more challenging in healthcare as it is not centralized like aviation and involves a large

number of facilities, diverse specialties, and multiple inter-related constituents (laboratory testing, pharmacies, etc.).

CONCLUSIONS

Despite the differences between aviation and health care,the use of successful aviation safety practices in health carehas resulted in improvements in patient safety. Improvingthe safety of health care is paramount. Restructuringhealthcare systems by incorporating the lessons and toolswe have acquired from aviation, an industry that has im-proved safety by leaps and bounds, can only continue to

improve patient safety. As described, there are differencesbetween aviation and health care, but the underlyingprinciples can be shared because of their overwhelmingsimilarities.

To advance the safety record of health care, it is essentialto educate healthcare workers and ancillary staff as well asmedical students and residents in such topics as patientsafety, the reporting of adverse events and near misses, andhuman factors and their effects on patient safety. In addi-tion to education, patient safety in health care can be im-proved as follows: (1) the creation of a safety cultureconsistently present to ensure that individuals reportevents and near misses in a confidential and nonpunitivesystem, an approach that could remove barriers to re-porting; (2) the encouragement of reporting of safetyevents to identify areas of potential risk and prevent ad-verse events; (3) the development of a well-established andstandardized reporting system to include all types ofhealthcare delivery systems and healthcare professionals ashealth care, unlike aviation, is decentralized; (4) the de-velopment of a system to link deidentified data from error-reporting databases nationally; (5) the identification oftrends in reported errors; (6) the national communicationof findings to healthcare delivery systems and individuals;and (7) the institution of system-based process improve-

ments in health care and patient safety. With these goals inmind, let us challenge health care to meet the CAST goal inaviation: to reduce the mortality risk in health care at least50% from 2010 to 2025.5

ACKNOWLEDGMENTS

Come Fly With Me was composed by Jimmy Van Heu-sen with lyrics by Sammy Cahn. The author thanks HalLeonard Corporation, Maraville Music Corporation,Warner Chappell, Alfred Music Publishing, and BartonMusic and Affiliates for permitting the use of the song title.

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