Celebrity Voices Join Call For Medical Patient Safety Board

Applying The Lessons of Aviation Safety to the Medical Industry

The National Transportation Safety Board (NTSB) has made a big impact on the safety of commercial aviation in the last few decades.

The risk of death on a commercial airplane was slashed from 1 in 2 million in the 1970s to 1 in 10 million today.

Perhaps the country’s most famous airline pilot, Captain “Sully” Sullenberger, who successfully landed an aircraft on the Hudson River in January 2009, said that the NTSB’s reports on accidents helped change federal regulations, airline policies, and pilot actions.

Captain Sullenberger believes that other industries can benefit from following the aviation model.

Many argue that a similar body which creates a direct link between investigating instances of medical malpractice and implementing preventative action is desperately needed in the field of medicine.

Right now knowledge about medical malpractice and how to prevent them generally stays within individual hospitals.

One measure, the Patient Safety and Quality Improvement Act of 2005, tried to change that by getting voluntary, confidential reporting of medical errors to designated patient safety organizations (PSOs).

Thus far, 77 PSOs are recognized by the Department of Health and Human Services.

It is too early to tell if or how they are improving patient safety.

However, advocates for those panels explain that the organizations don’t have the investigative reach or power of comparable organizations in other industries like the NTSB.

That is why proponents are calling for a new panel with more far-reaching powers.

Ideally, this proposed panel would be a governmental agency like the NTSB – which has board members appointed by the President for five year terms.

Only a government entity, it is argued, could be independent enough from the industry to be able to do meaningful investigations and impartial work.

Actor Dennis Quaid Calls for Improved Medical Error Investigations

Captain Sullenberger is not the only famous name offering support for the creation of a centralized panel to investigate medical negligence.

Actor Dennis Quaid has been an outspoken proponent of improving the way medical errors are reported and used to improve care.

Quaid and his wife went through an experience that is every parent’s nightmare.

In 2007, his 12 day old twins developed infections and were rushed to the hospital.

However, while there, the babies almost died after they were given 1,000 times the appropriate dose of heparin.

This nearly lethal medical error was partly caused by the fact that 10,000 unit strength and 10 unit strength vials of the medicine looked almost the same and the higher units ones were kept in the same storage area.

Only 14 months earlier, a nearly identical heparin overdose happened at an Indianapolis hospital to six different babies, three of whom died from the medical mistake.

Even though the Indianapolis story received significant press coverage, the news accounts did not spur any safety changes at other hospitals to prevent similar accidents from happening.

Quaid vented that hospitals should not wait for a serious error to occur before taking action.

That is why he joined with patient advocates and aviation experts to promote this new patient safety panel idea.

He recently co-wrote an article about it entitled:

“We Do Not Have Bad People, We Have Bad Systems.”

Not everyone is sold on the idea

Of course there are some who reject the idea of a medical patient safety board modeled after the NTSB.

Skeptics say that the amount of medical errors dwarfs those in aviation, making it more difficult to replicate the NTSB’s success.

Yet patient safety experts like Michael Cohen of the Institute for Safe Medication Practices – which issued an alert for the heparin overdose problem after the Indianapolis incident — counter that more centralization is needed.

Mr. Cohen noted:

“We’ve had lots of reporting going on in this country, now even more so with PSOs. All of us put out this material that’s peer-reviewed, evidence-based and system-based as much as possible.

That doesn’t mean anybody does anything with it — that’s what’s so frustrating.”

What do you think?

Is the aviation model a good one for the medical industry to follow to finally take serious steps to prevent medical errors nationwide?