Improving Patient Safety: Lessons from the Airline Industry

Mark Auerman

The important 2000 study of the Institute of Medicine in the United States "To Err is Human" estimates that there are 50 to 99 thousand deaths per year related to medical error in the US. At a recent UHN Surgical Services Rounds Captain Mark Auerman, an Air Canada pilot specializing in competence assessment and training, opened the discussion of patient safety with a slide illustrating a dramatic reduction of the incidence of aircraft accidents. Over the past thirty years it has fallen from over forty to fewer than two per thousand departures. He analyzed the "runway excursion" of an Air France plane last year in Toronto which almost resulted in a highway incursion. The cause was pilot error. Errors in the airline industry are primarily caused by problems within the crew (66%). Only 13% are from problems with the airplane. Mark, a nineteen-year veteran pilot, startled everyone by stating "I've never had a perfect flight". This reflects the contrast between the culture of his industry, which plans on coping with imperfection, and the misleading culture of perfectionism in surgery.

Competence of airline pilots is regulated. They are required to undergo a medical examination every six months after the age of forty. They retire at age sixtyfive -- age sixty at Air Canada. They undergo six training/ evaluation sessions per year, including four days of simulator training and regular line operational safety checks in the air, conducted by a pilot/evaluator "in the jumpseat". They spend a classroom day with the full crew as part of the program of training in crew resource management. The pilot's role is similar to that of the anaesthetist -- extremely busy at the beginning and the end of the case. Though technology allows pilots to "fly by the button" there has been recent emphasis on manual flying, to be sure they can manage unexpected and unprogrammable emergencies.

Challenging personalities are managed by one-on-one training. Oversight includes air safety reports, flight data analyses and the advanced qualification program. The flight data analyses use de-identified data. The flight data recorder is retrieved if variants are found, like "tail strikes" on take-off or landing.

The problems of individual pilots are discovered in the simulators. The union is the gatekeeper overseeing safety, a wise tradition that dates back to the guilds. Those who are not able to meet the standard are taken off revenue flying. The training intervals are based on data and experience, as some pilots take off several times per day, and others may take off once and fly for nineteen hours. The mantra of the training program is "we fly the way we train and train the way we fly."

Line operational safety audits look at "threats" as well as errors. The safety barriers in James Reason's Swiss cheese diagram are: 1. Policies and procedures, for example, "disarm the doors and cross check" (to be sure ground personnel are not injured by emergency slides inflated like airbags when they open the doors); 2. Checklists; 3. Automation, though equipment can vary; 4. Crew resource management skill; and 5. Aircraft handling skill. The threats to the safety of the plane come from weather, fatigue, malfunction, illness and complacency. When accidents occur despite all of these safety barriers, the euphemism describing them is "undesirable aircraft state", analogous to our "adverse event" terminology.

CULTURAL CHANGE

Air safety reports are kept confidential and no disciplinary action is taken on the basis of these reports. The integrated safety management system includes self-reporting, timely feedback to the initiators of the report, audit, and quality assurance. Important elements of the cultural change in air safety include emphasis on these values: 1. We must recognize we make mistakes and devise ways to recognize, manage and prevent them; 2. Training must be skill-based; 3. Crew performance, not just individual performance must be strengthened; 4. Fatigue is managed by a 13-hour "duty gate". This is important because pilots are paid more when they are in the air, analogous to fee for service payment for performing surgery.

Air Canada spends roughly half of its budget on people and half on fuel and equipment. Pilots grade each other using videos. Aging pilots have "naturalistic decision- making" which is somewhat like surgical intuition. Their decisions are quicker and more often right.

M.M.