For some time, I have been interested in the different approaches to the personal safety by airlines and the medical profession. If you travel by air, you can be confident that safety is paramount, especially when using reputable companies. They are controlled by tight regulations but more importantly, it is totally recognised that if there is the slightest doubt about the commitment to passenger safety, people simply will not use that particular airline.
By contrast, the attitude to patient safety in hospitals is positively cavalier. Some years ago it was estimated that in the USA, the number of people exposed to unnecessary hospitalization annually is 8.9 million. Even more revealing is that the total number of iatrogenic deaths was 783,936 (1).
I have just discovered that a detailed comparison has been done by Thomas J Moore in his book entitled “Heart Failure: A Critical Inquiry into American Medicine and the Revolution in Heart Care”. Remarkably, this was first published in 1989 (2). I am finding it absolutely fascinating and it provides great insight. Although it is based on his experience in the USA, many of the elements are also applicable to many other countries, including the UK. This is because similar attitudes prevail, especially in the English-speaking world.
Operating an airline like an operating theatre
This blog is based on the chapter “No Way to Run an Airline”, which I have used as the title. It begins by spelling out the scenario that would apply if airlines were run in the same way as hospitals. Essentially this would mean that:
- The safety record of each airline is kept secret;
- The pilot controls the safety procedure in each aeroplane;
- The pilot (captain) of the aircraft is the sole judge of what is safe;
- The only way that a pilot with a poor safety record to be removed is by a vote taken by all the other pilots of that airline;
- When a crash occurs, there is a total blackout of all news;
- Airlines vary widely in the thoroughness of investigations into accidents, which are necessarily always conducted;
- Secret inquiries are normally done by the close colleagues of the pilot involved in an accident;
- There are large differences in the safety records of airlines, which are not normally available to the public;
- The USA government has practically no role in airline safety.
The similarities between an airline and a hospital
According to Moore, there are many basic similarities between hospital-based medical care and airline transport. Both of these are involved with expensive and complicated technology, which are in routine use. Thousands of lives are at risk every day in the two activities. In both of them there are highly trained staff, which demand high levels of alertness, coordination and teamwork. They are both extremely costly worldwide enterprises.
Operating procedures in an airline
The following conditions apply in the USA and most other countries:
- Every aircraft must have a certificate of airworthiness;
- An aircraft may depart from an airport only if it has permission from a traffic controller;
- Any change in course has to be approved;
- All maintenance procedures must be recorded;
- All conversation in the cockpit during a flight is recorded;
- Instrument readings are independently monitored and recorded;
- Accidents are investigated by independent agencies;
- Performance data on crashes open to the general public.
Operating procedures in a hospital
These points refer specifically to open-heart surgery in the USA, but it is probably reasonable to conclude that they are also applicable to many other aspects of surgery:
- A hospital can conduct surgery without any governmental approval;
- The choice of equipment, facilities and staffing are a matter for each individual hospital and can vary enormously;
- There are no specific standards for the qualifications of the physician;
- This means heart surgery can be performed by a general surgeon, a general practitioner, or an assistant without either a physician’s or nurse’s formal education and license;
- If there are a unusual number of deaths, the hospital can decide what inquiry, if any, should be conducted;
- The official record of events during surgery, including errors that result in the death of a patient, is written and retained by the surgeon himself;
- If it determined that a death occurred because of negligence, avoidable error, defective equipment, or lack of training, the hospital has no legal duty to inform any authority.
The safety record in hospitals
In the light of this it is not in the least surprising that there is such a poor record in hospitals and that the death rates noted above are so appalling. In many cases it is far too easy for the failures to be ignored. Even worse, there is no pressure or incentive to tackle problems if they are identified. There is clearly little interest in trying to understand the issues so improvements can be made. Nevertheless, some investigations have provided relevant information that is extremely disturbing. An evaluation of the use of pacemaker in 382 cases concluded that 20% should never have been implanted and expressed doubts about the need for another 36%. A study in Boston found that of 815 patients, 36% suffered an iatrogenic illness. In 9%, the injury was so severe that it caused permanent disability or contributed to their death, which occurred in 2%.
The major issue was adverse side effects of drugs or combinations of drugs. A study in Seattle found that there was adequate information on how to administer intravenous drugs in less than 25% of the instructions.
On a more mundane level, it was noted that hand-washing was either not done or done improperly. Here in the UK, this problem has probably been addressed following the high levels of infection that was experienced in hospitals some years ago.
The fact remains that most hospitals are a law unto themselves when it comes to the emphasis on patient safety. The full extent of this becomes apparent from the comparison with passenger safety procedures in the airline industry. The costs of the failure in medicine with respect to human suffering and finance are enormous. It certainly is another example of the inability of governments to take this issue seriously. As a first step, we should be demanding much more openness about the information. At the very least, this would help to make people generally aware of what is clearly a scandalous state of affairs.
- T J Moore (1990). “Heart Failure: A Critical Inquiry into American Medicine and the Revolution in Heart Care”. Touchstone (Simon & Shuster) ISBN 0-671-72444-4