Healthcare can learn some important lessons from a new report outlining the causes of an Asiana Airlines jet crash in San Francisco last July.
A combination of insufficient monitoring, automation reliance, increased workload and fatigue were likely to blame for the crash, according to the report released Monday by the U.S. National Transportation Safety Board.
Concerns about many of the same factors are prevalent in healthcare, especially as the industry moves toward greater reliance on healthcare information technology—from safety checklists to electronic health records.
A study released last week looking at the implementation of electronic health records found, for example, the same automated features intended to increase efficiency and safety were often confusing or misunderstood by those using them. That threatens patient safety.
Hospitals planning to add new software or make updates, especially while aiming to quickly meet meaningful-use or ICD-10 guidelines, were advised to be strategic and proactively include ways to monitor events.
In an article on the automation of surgical safety and other hospital checklists, experts noted that technology is only a tool—an organizational culture of change is needed to ensure their correct use.
“If you haven't thought deeply about relationships or communication patterns and culture and leadership, you often don't get what you hope for,” said Dr. Bob Wachter, associate chairman of the department of medicine at UCSF Medical Center in San Francisco. While researching a book he's writing about health IT, Wachter spent a day with Boeing engineers who design cockpit safety alerts for airline pilots. The degree of care used by aviation engineers to integrate the electronic workflow is needed in healthcare, he said.
And some patient safety leaders interviewed recently by Modern Healthcare noted that nearly 15 years after the Institute of Medicine's landmark report “To Err Is Human” ignited concerns about patient safety, there is still no effective set of regulations to protect people once they have entered the healthcare delivery system.
Hospitals may need the health equivalent of the Federal Aviation Administration, which sets the rules and then enforces them, and then the National Transportation Safety Board, which investigates accidents, said Dr. Lucian Leape, Harvard health professor and a founder of the National Patient Safety Foundation.
“We need to have that in healthcare, and I don't see that happening,” he said.
The pilot on Asiana Airline flight did not fully understand how the airplane's automated features interacted, explained acting NTSB chairman, Christopher Hart, in a blog post about the investigation. The accident reports and recommendations resulting from the accident need to be as close to perfect as possible, he said, noting that getting it right helps to prevent future accidents and save lives.
Follow Sabriya Rice on Twitter: @MHSRice
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