Patient Safety Leaders Propose 'NTSB for Healthcare'


Successful safety efforts from aviation provide critical lessons for addressing the "crisis of waste and harm" in the U.S. healthcare system, according to a special article, An NTSB for Healthcare Learning from Innovation: Debate and Innovate or Capitulate, in the April issue of the Journal of Patient Safety.

An independent body modeled after the National Transportation and Safety Board (NTSB) is a promising approach to combat the systemic issues compromising patient safety, according to the article, authored by a quartet of pilots and safety experts with special experience in the "overlap between aviation and healthcare."

"All four of us know that an NTSB type program for healthcare and more aggressive adoption of aviation best practices will save lives, save money, and bring value to our communities," write the authors, led by Dr Charles R. Denham. Dr Denham is Founder and Chairman of the Texas Medical Institute of Technology (TMIT), a private, not-for-profit medical research organization that supports development and dissemination of patient safety practices.

His coauthors are US Airways Flight 1549 pilot Chesley B. "Sully" Sullenberger; actor turned patient safety advocate Dennis Quaid; and aviation safety expert John J. Nance. Their article, in print and online now in the Journal of Patient Safety, introduces some of the ideas discussed in a new TMIT documentary, titled "Surfing the Healthcare Tsunami: Bring Your Best Board." The documentary will premiere on April 27 at the National Press Club in Washington, D.C.

In the article, Denham and colleagues highlight some key similarities between healthcare and aviation: "[H]igh risk and complexity, dependency on human performance factors, and the potential to generate highly reliable performance ONLY IF basic safety principles are provided by invisible support systems."

In aviation, cooperative efforts between government agencies and industry have led to remarkable improvements in safety. Since the introduction of the Commercial Aviation Safety Team in 1998, the fatality rate of commercial air travel in the United States has decreased by more than 80 percent.

Those unprecedented gains have led some observers to suggest that a similar approach could help to address the ongoing crisis in healthcareincluding high rates of medical errors leading to patient harm and chronic waste of healthcare resources. Expressed in aviation terms, the losses are equivalent to 20 Boeing 757 airliners crashing each week, with $10 million in each cargo hold.

Denham add their voices to the call to establish an "NTSB for healthcare"an independent agency that, like the NTSB, views every death as a preventable occurrence. When it concludes investigations of aviation accidents, the NTSB issues "Blue Cover Reports" on its findings and recommendations.

An NTSB for healthcare could issue "Red Cover Reports" sharing the "experiential safety information" that is absolutely essential to reduce patient injuries. Currently, this information is "submerged" by fear of litigation and lack of co-operation within the healthcare profession. A series of Red Cover Reports on the most important safety problems would provide a "disciplined, systematic approach" to understanding the causes of preventable patient harmsand, most importantly, what must be done to keep such events from happening again.

The authors believe that "Ground Zero" in the war against healthcare waste and harm is the decisions made and policies set by healthcare trustees and administrators in the boardroomwhich set the stage for the actual provision of care at the patient's bedside. "High performance care and safe care exist at the intersection of leadership, practices, and technologies," they write.

Produced in collaboration with other patient safety leaders, Surfing the Healthcare Tsunami is the latest in a series of TMIT documentaries highlighting "extraordinary impact through ordinary things." The producers hope it will provide a call to action for all people interested in healthcare to repair, develop, and enhance the invisible safety-net that keeps patients and caregivers safe.

Surfing the Healthcare Tsunami will appear on the Discovery Channel on April 28, with repeated showings over subsequent weeks. In the second part of their articleto be published soon in Journal of Patient SafetyDenham and coauthors "challenge healthcare suppliers, providers, and purchasers to become role models and fully embrace patient-value-centered-care that has as an intrinsic property safety and avoidance of healthcare harm."

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