(View entire post here)

The following is from Safe Patients, Smart Hospitals. A longer excerpt is available on the book page.

"The idea of a checklist really started to make sense to me when I was preparing to attend a seminar on patient safety and medical errors in Salzburg, Austria. Among the long lists of experts on safety, I saw that James Reason would also be attending the seminar. On the flight over, I read Reason's book Managing the Risks of Organizational Accidents, which contained detailed information about aviation safety programs--specifically the use of checklists to improve safety.

Though familiar with the idea of using checklists in aviation, I had never really examined the theory. I was captivated. The parallels between aviation and medicine were striking. Decision, control and inevitably the safety of passengers and patients were regulated to one individual--in aviation, pilots; in medicine, doctors. Both professionals were expected to master complicated equipment and science that was constantly evolving and changing and in both arenas, errors could easily result in death.

But there were also significant differences between medicine and aviation. In aviation the general acceptance that humans are fallible was fundamental to the checklist's success. Once this truth had been universally accepted, the industry was able to design systems that could prevent or catch inevitable errors before they caused harm, or to minimize the harm from errors that were not identified.

The health care community, however, has difficulty admitting that well-meaning, highly trained, competent doctors predictably and continuously make mistakes. So, when errors inevitably happen, the event and everyone involved are shrouded in guilt, shame denial, and secrecy. Also, medicine is infinitely more complex than aviation. The amount of information that a doctor must retain to practice medicine is mind-boggling. To put this in perspective, what a pilot needs to know to fly a specific aircraft, say a Boeing 747, is the equivalent to what a doctor must remember to perform one single procedure.