My dad has a strange sense of humor.  An example was when he would go away to a conference on an airplane, and the family would drive him to the airport, we would often walk past the “flight insurance” machine on our way to the gate (unobstructed, at the time, by security). We would stop and he would look at my mother and ask her if she was feeling lucky and did she want to put some money in the machine. She, as I recall, would say “Oh, Bobby” and would not. I came to realize as I grew up that he was asking her to bet on his crashing. I don’t know if she would go back later and take the bet (after all, it was only a dollar).

Flying is one of those activities that has become much safer over the last 70 years. with deaths decreasing from 1 for every one million person-miles flown to 1 for every 2 BILLION (or a factor of `1/1000).  In fact, in America in 2010, there was only 1 person who died in an aircraft related accident. This improvement was accomplished as the result of a culture in the industry. The dynamics of the industry went from the pilot as the “captain of the ship” to a concerted team approach (described here) where the FAA is a central repository that provides information, sets rules, and works with industry to assure process (and outcome) improvement. Flying is so safe that the insurance machines have been replaced with Starbucks.

Contrast that with the news story of the day, “UTMC Nurse Tosses Out Kidney, Ruins it.

A kidney removed from a Toledo man at the University of Toledo Medical Center that was supposed to be transplanted into his older sister was instead thrown away with medical waste by a nurse — a rare accident that medical experts said is probably a one-of-a-kind incident in the United States.

To quote the non-involved expert called in by the Toledo paper to comment:

“It was a good decision not to use it,” Dr. Harmon said after being told about the kidney removed from the Toledo patient. “This is unfortunately what medicine is like — it is not perfect and there have been far worse cases where the donor has died,” Dr. Harmon said. “This is tragic, and this is horrendous, and I am sure the people involved are just killing themselves over it.”

Although this particular event may have been isolated,  physicians operate on the wrong part of the patient up to 40 times a week in this country. These are referred to by experts in patient safety as “never events” because, well, do I have to explain it? Surgeons cite “error in communication” to be the root cause.

Does medicine have to be like this? In 1999, the Institute of Medicine issued a report entitled “To Err is Human.”

One of the report’s main conclusions is that the majority of medical errors do not result from individual recklessness or the actions of a particular group–this is not a “bad apple” problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. …Thus, mistakes can best be prevented by designing the health system at all levels to make it safer–to make it harder for people to do something wrong and easier for them to do it right.

The key to avoiding these events is to think like the folks flying the planes. Not just the pilots, but all the folks. As described in JAMA:

[To fix this we will need to change the system we need] transparency, combined with a commitment to and training in crew resource management (everyone in the room has a shared sense of responsibility for the outcome of the case). [This] enables doctors to hold themselves accountable to the standard of care they would wish for their own family members. This combination of ingredients offers far more potential than financial penalties or other regulatory actions for sustained process improvement in the operating rooms of America.

To move to the next level of safety, we in medicine need to learn how to talk to each other. Not as doctor/nurse/assistant but as members of the same team. Or, I suppose we could put those insurance machines in hospitals.

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