Lessons Healthcare Can Learn from Asiana Flight 214

On July 6th, Asiana flight 214, a B-777, hit the sea wall on approach to San Francisco airport (SFO). Three passengers died.

Screen Shot 2013-10-11 at 7.16.54 AMI recently received a well-written and insightful article describing what we in healthcare can learn from the cause-analysis findings coming forward from this unfortunate event. Richard Lockwood, AVP for Quality and Outcomes at MedStar Washington Hospital Center (MWHC) passed on the article, written by Steve Harden, as he found it useful given MWHC has been on a high reliability (HRO) seeking Journey the past two years. Richard’s experiences are guideposts as we embark upon the same journey for our entire health system. Having started his career in the commercial nuclear power industry, and having been a key contributor to the design and execution of the that industry’s HRO journey, Richard has proven an excellent resource to me and others when it comes to understanding some of the barriers healthcare organizations may face as they continue on their resilience journey.

Excerpts from the article follow, and more information on the author, Steve Harden, can be found here:

The effort to stop patient harm due to preventable medical error in healthcare can be assisted by examining some of the factors in the loss of life in aviation…Critical lessons for healthcare can be gleaned from…what is known about the training and culture that pervades the airlines in South Korea…Here are four lessons that healthcare can learn from the tragic accident.

1. Beware of over-reliance on technology: The pilot in command of the flight that day had over 10,000 hours of flight experience…However few of those hours were logged while in actual physical control of the airplane – what pilots call “hand-flying.”…Almost all of their flight time is accrued while the airplane is actually being “flown” by the computer.

Over-reliance on technology causes several issues including degradation in basic flying skills, and a tendency for a “lack of engagement and mindfulness” in monitoring the computer and the computer generated flight path.

The lesson for healthcare is clear…Electronic medical records, computerized physician order entry, and decision support tools will never replace “basic flying skills” in medicine. 

How many times have we heard our informatics teams share that same advice when we ask them why our EMR’s are not solving many of our safety problems?

2. Culture eats initiatives for lunch: …Culturally, it is bad form to mention something that might reflect badly on the senior person of the group…During the last two minutes of the accident flight, the descent path to the runway was..clearly wrong, yet none of the other three crew members in the cockpit said anything to the Captain.

The lesson for healthcare? You may have a TeamSTEPPS program. You may have a great Lean process improvement program. Neither will yield the sustainable results you want if you don’t work on your organizational culture.

3. Protecting the powerful is counter-productive: …You can overcome 3000 years of culture, but it takes a concentrated effort by leadership to over-communicate the expectations, to reward the new behaviors, to celebrate the results, to personally model the new behaviors, and to eliminate those unwilling or incapable of change.

The lesson for healthcare? As Harden points out, allowing the mindset that “I know s/he is disruptive and hard to work with, but s/he is a big producer”, cannot be tolerated if an organization wants to achieve success in their HRO seeking journey. Disruptive and abusive behaviors are in direct conflict with high reliability seeking cultures which embrace respect and caring for fellow associates and team members.

For me, the following point referenced from Harden’s article is the most important take-away from this learning. We see many wonderful examples every day of caregivers speaking up and taking action when needed – similar to what Harden describes:

4. Even one person who can speak up and be assertive can save a life: Despite all the cultural barriers that might have prevented it, one of the Asiana flight attendants used a TeamSTEPPS behavior when it mattered most. After the crash and when the airplane had come to a stop, the Captain announced that the passengers should not evacuate. One of the flight attendants saw flames outside the window and called the Captain on the intercom to let him know they needed to evacuate. This willingness to speak up undoubtedly saved a lot of lives.

We know many of the answers, and what needs to be done to make healthcare safer–culture change, stop protecting the powerful especially when safety is at stake, and celebrate those remarkable caregivers who speak up even when they fear possible retaliation for voicing their safety concern. We hear these recommendations over and over. It’s not rocket science, but they are still challenging to put in place while many of the historical incentives remain misaligned.

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