The idea that healthcare has a lot to learn from industries that are inherently risky but nonetheless manage good safety records – like aviation – has proven enormously persuasive. Aviation provides many examples of how to improve things that are currently not done as well as they could be, including effective teamwork and standardisation of routines.
But there are important differences between healthcare and air travel. Aviation incidents, when they occur, are dramatic, headline-grabbing events. And when a plane crashes, the crew has as much chance of going down as the passengers, so the stakes are as high for them as those they serve. By contrast, when errors occur in healthcare, they tend to harm one patient at a time, and clinicians are not affected by the outcome in the same way as patients.
Further differences lie in the scale and nature of the systems, and the constraints on what can and can’t be done. In aviation, the number of different types of personnel and types of procedure is limited: flights are scheduled and airlines can control exactly how many people are on a flight. Both crew and passengers can be compelled to comply with safety instructions, and those thought likely to pose a security risk or cause trouble can be stopped from boarding.
Hospitals are vastly more complex. Delivering good healthcare may require crossing multiple organisational, professional and institutional boundaries. Healthcare organisations conduct many thousands of different procedures, involving multiple staff, and are subject to problems of uncontrollable surge. But they often lack the ability to turn people away either because of capacity problems or because individuals pose a risk in some way.
Many of the factors that disrupt good care may be outside the control of individuals or teams, and they are dealing with autonomous patients, who may either decline or be unable to cooperate with what others feel would be in the best interests of safety. And hospital facilities, sometimes built in centuries past, are often poorly designed for the tasks they now undertake.
So, though there is much to be learned from aviation, it will never provide the full answer for healthcare, and some of its ‘solutions’ may require more adaptation to make them work in healthcare than is often recognised. In fact, looking at examples where achieving safety has been much more challenging, such as road safety, may in fact provide important lessons for patient safety.
As in healthcare, road safety accidents are only rarely headline-grabbers. Road use has the same deceptive familiarity as healthcare, and everyone has had a prang or two.
Road transportation suffers from many problems endured by healthcare: unsuitable physical infrastructure, poorly coordinated design, complexity introduced by individual autonomy and preferences, unpredictable surges, behaviour that is not always consistent with what is known to be safety-promoting, and a wide range of expertise and experience among road users, among many other things. But though it is not fully there yet, road transportation has succeeded in becoming much safer.
Both casualties and deaths on the road have shown steep declines since the 1960s (see the Office for National Statistics website), even though road traffic has substantially increased. Nearly 8,000 people were killed on the roads in the UK 1966, compared with just over 2,200 in 2009. The key is that improvements have been brought about by a range of strategies, targeting different levels and facets of the problem.
Structural and regulatory changes have gone hand in hand with large scale behavioural and cultural adjustments, and improvements to technology and infrastructure. For example, legal interventions have targeted unsafe behaviours such as speeding and drink driving; car design has massively improved; and standards of driving have improved through more rigorous training and licensing regimes.
Some interventions have removed choice and autonomy (such as removing the right to travel without a seatbelt, or to drive a banger that’s deemed not to be road worthy), but over time the resistance to them has diminished. That many people continue to be killed every year shows how difficult it can be to achieve institutional, cultural and behavioural change across the board, especially once the fabled low-hanging fruit has been picked.
Clearly, I am not trying to argue that road safety is a perfect model for patient safety. But neither is aviation. We need to be smart about how we learn from other areas, recognise that we need to select and combine many different instruments, figure out the optimal balance of ‘hard’ and ‘soft’ interventions, and keep working at the wicked problems.
Mary is Professor of Medical Sociology at the University of Leicester and a member of The Health Foundation's Improvement Science Network.
But there are important differences between healthcare and air travel. Aviation incidents, when they occur, are dramatic, headline-grabbing events. And when a plane crashes, the crew has as much chance of going down as the passengers, so the stakes are as high for them as those they serve. By contrast, when errors occur in healthcare, they tend to harm one patient at a time, and clinicians are not affected by the outcome in the same way as patients.
Further differences lie in the scale and nature of the systems, and the constraints on what can and can’t be done. In aviation, the number of different types of personnel and types of procedure is limited: flights are scheduled and airlines can control exactly how many people are on a flight. Both crew and passengers can be compelled to comply with safety instructions, and those thought likely to pose a security risk or cause trouble can be stopped from boarding.
Hospitals are vastly more complex. Delivering good healthcare may require crossing multiple organisational, professional and institutional boundaries. Healthcare organisations conduct many thousands of different procedures, involving multiple staff, and are subject to problems of uncontrollable surge. But they often lack the ability to turn people away either because of capacity problems or because individuals pose a risk in some way.
Many of the factors that disrupt good care may be outside the control of individuals or teams, and they are dealing with autonomous patients, who may either decline or be unable to cooperate with what others feel would be in the best interests of safety. And hospital facilities, sometimes built in centuries past, are often poorly designed for the tasks they now undertake.
So, though there is much to be learned from aviation, it will never provide the full answer for healthcare, and some of its ‘solutions’ may require more adaptation to make them work in healthcare than is often recognised. In fact, looking at examples where achieving safety has been much more challenging, such as road safety, may in fact provide important lessons for patient safety.
As in healthcare, road safety accidents are only rarely headline-grabbers. Road use has the same deceptive familiarity as healthcare, and everyone has had a prang or two.
Road transportation suffers from many problems endured by healthcare: unsuitable physical infrastructure, poorly coordinated design, complexity introduced by individual autonomy and preferences, unpredictable surges, behaviour that is not always consistent with what is known to be safety-promoting, and a wide range of expertise and experience among road users, among many other things. But though it is not fully there yet, road transportation has succeeded in becoming much safer.
Both casualties and deaths on the road have shown steep declines since the 1960s (see the Office for National Statistics website), even though road traffic has substantially increased. Nearly 8,000 people were killed on the roads in the UK 1966, compared with just over 2,200 in 2009. The key is that improvements have been brought about by a range of strategies, targeting different levels and facets of the problem.
Structural and regulatory changes have gone hand in hand with large scale behavioural and cultural adjustments, and improvements to technology and infrastructure. For example, legal interventions have targeted unsafe behaviours such as speeding and drink driving; car design has massively improved; and standards of driving have improved through more rigorous training and licensing regimes.
Some interventions have removed choice and autonomy (such as removing the right to travel without a seatbelt, or to drive a banger that’s deemed not to be road worthy), but over time the resistance to them has diminished. That many people continue to be killed every year shows how difficult it can be to achieve institutional, cultural and behavioural change across the board, especially once the fabled low-hanging fruit has been picked.
Clearly, I am not trying to argue that road safety is a perfect model for patient safety. But neither is aviation. We need to be smart about how we learn from other areas, recognise that we need to select and combine many different instruments, figure out the optimal balance of ‘hard’ and ‘soft’ interventions, and keep working at the wicked problems.
Mary is Professor of Medical Sociology at the University of Leicester and a member of The Health Foundation's Improvement Science Network.
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