Patient Safety Leaders Propose ‘NTSB for Healthcare’


Board Room Is Ground Zero for Addressing ‘Crisis of Waste and Harm,’ Says Article in Journal of Patient Safety Authored by Leading Patient and Aviation Safety Leaders Including Pilot Chesley “Sully”Sullenberger and Actor/Patient Safety Activist Dennis Quaid

Newswise — Philadelphia, Pa. (April 26, 2012) – Successful safety efforts from aviation provide critical lessons for addressing the "crisis of waste and harm" in the U.S. healthcare system, according to a special article, “An NTSB for Healthcare – Learning from Innovation: Debate and Innovate or Capitulate,” in the April issue Journal of Patient Safety. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

An independent body modeled after the National Transportation and Safety Board (NTSB) is a promising approach to combat the systemic issues compromising patient safety, according to the article, authored by a quartet of pilots and safety experts with special experience in the "overlap between aviation and healthcare."

‘NTSB for Healthcare’ Could Save Lives, Reduce Costs"All four of us know that an NTSB type program for healthcare and more aggressive adoption of aviation best practices will save lives, save money, and bring value to our communities," write the authors, led by Dr Charles R. Denham. Dr Denham is Founder and Chairman of the Texas Medical Institute of Technology (TMIT), a private, not-for-profit medical research organization that supports development and dissemination of patient safety practices (http://www.safetyleaders.org/).

His coauthors are US Airways Flight 1549 pilot Chesley B. "Sully" Sullenberger; actor turned patient safety advocate Dennis Quaid; and aviation safety expert John J. Nance. Their article, in print and online now in the Journal of Patient Safety, introduces some of the ideas discussed in a new TMIT documentary, titled Surfing the Healthcare Tsunami: Bring Your Best BoardTM. The documentary will premiere on April 27 at the National Press Club in Washington, D.C.

In the article, Dr Denham and colleagues highlight some key similarities between healthcare and aviation: "[H]igh risk and complexity, dependency on human performance factors, and the potential to generate highly reliable performance ONLY IF basic safety principles are provided by invisible support systems."

In aviation, cooperative efforts between government agencies and industry have led to remarkable improvements in safety. Since the introduction of the Commercial Aviation Safety Team in 1998, the fatality rate of commercial air travel in the United States has decreased by more than 80 percent.

Those unprecedented gains have led some observers to suggest that a similar approach could help to address the ongoing crisis in healthcare—including high rates of medical errors leading to patient harm and chronic waste of healthcare resources. Expressed in aviation terms, the losses are equivalent to 20 Boeing 757 airliners crashing each week, with $10 million in each cargo hold.

'Ground Zero—The Boardroom, Not the Bedside'Dr Denham add their voices to the call to establish an "NTSB for healthcare"—an independent agency that, like the NTSB, views every death as a preventable occurrence. When it concludes investigations of aviation accidents, the NTSB issues "Blue Cover Reports" on its findings and recommendations.

An NTSB for healthcare could issue "Red Cover Reports" sharing the "experiential safety information" that is absolutely essential to reduce patient injuries. Currently, this information is "submerged" by fear of litigation and lack of co-operation within the healthcare profession. A series of Red Cover Reports on the most important safety problems would provide a "disciplined, systematic approach" to understanding the causes of preventable patient harms—and, most importantly, what must be done to keep such events from happening again.

The authors believe that "Ground Zero" in the war against healthcare waste and harm is the decisions made and policies set by healthcare trustees and administrators in the boardroom—which set the stage for the actual provision of care at the patient's bedside. "High performance care and safe care exist at the intersection of leadership, practices, and technologies," they write.

Produced in collaboration with other patient safety leaders, Surfing the Healthcare Tsunami is the latest in a series of TMIT documentaries highlighting "extraordinary impact through ordinary things." The producers hope it will provide a call to action for all people interested in healthcare to repair, develop, and enhance the invisible safety-net that keeps patients and caregivers safe.

Surfing the Healthcare Tsunami will appear on the Discovery Channel on April 28, with repeated showings over subsequent weeks. In the second part of their article—to be published soon in Journal of Patient Safety—Dr. Denham and coauthors "challenge healthcare suppliers, providers, and purchasers to become role models and fully embrace patient-value-centered-care that has as an intrinsic property safety and avoidance of healthcare harm."

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About Journal of Patient SafetyThe Journal of Patient Safety is dedicated to presenting research advances and field applications in every area of patient safety. While Journal of Patient Safety has a research emphasis, it also publishes articles describing lessons learned from near-miss incidents, system modifications that are barriers to error, and the impact of regulatory changes on healthcare delivery. This mix of research and real-world findings makes Journal of Patient Safety a valuable resource across the breadth of health professions and from bench to bedside.

About Lippincott Williams & Wilkins Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes. LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2011 annual revenues of €3.4 billion ($4.7 billion).

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