|
Editorial Archive
Aviation industry has focused on safety with great success. The ideology it to focus on systems and training - not looking for negligence in the individual pilot‘s performance. They have created an atmosphere where errors are accepted as part of human performance - and have used the errors to improve systems and performance. Thus, accidents are rare in the air. Medicine focuses on skills and individual performance. We are all taught to strive for perfection in performing our tasks. Reporting errors gives a feeling of not performing up to standards. There are many differences between the mechanical environment in the cockpit and the treatment of patients where the correct response in not always given. However, there are many similarities and we have something to learn. "If we had to live with 99.9% safety we would have two unsafe landings each day at O‘Hare....." WE Deming cited by Leape (1). When something goes wrong in medicine, there seems to be a need for scapegoats. The public and hospital management will look for somebody to blame in order to reduce the tension for the rest. It takes time and strong will to create a culture for reporting errors without making the reporter loose his face and prestige. This training needs to be coached from the top. Everybody makes mistakes. M&M conferences should not be made a forum for finding the one who made the error - rather a collective search for system failure. Health workers are conscientious people with high standards of professional conduct. It may be difficult to live with the appreciation of having made the wrong decision if it leads to damage. We must see the errors as valuable information about how our systems work. The errors have value only, however, only when used to improve system or training. This is the duty of the chief of staff. Analysis of aviation accidents has often shown that lack of communication or even hostile communication has preceded the accident. The whole team has a responsibility for making the players feel comfortable enough to do his best. The patient does not need brilliant soloist but a team that can communicate and make each other perform at his best. 1. Leape LL.Error in medicine.JAMA 1994: 272:1851-7 |
||||
Advertisement
Latest News
Abstracts from EACTA 2008The Abstracts from EACTA 2008 is now available online. Go to:
» www.JCVAonline.com
and press the black oval on the front page with a link to the Abstracts.
JCVA
The Journal of Cardiothoracic and Vascular Anesthesia (JCVA) is now the official journal of the European Association of Cardiothoracic Anesthesiologists (EACTA)......
» Read more