Medical errors and their fixes
Re: Your article about medical errors in healthcare institutions [“ ‘It’s Never Just One Thing’ That Leads to Serious Harm,†Jan. 28], we have seen this phenomenon before, in the aviation industry.
After a series of catastrophic crashes in the 1970s, the Federal Aviation Administration asked the NASA Ames Research Center to examine some of the “human factors†that led to errors with devastating consequences.
They developed the principles of what has come to be known as Crew Resource Management, which focuses on communication and decision-making to lead to more informed, and better, outcomes.
Such training is now required of all commercial airline crews, and it has made its way into the maintenance and air traffic control arenas. The result has been a significant decrease in airline accidents in the U.S. over the last 30 years.
Many in the healthcare industry have looked to these principles as a means of reducing medical errors and increasing patient safety.
These are not quick-fix solutions. It takes many years to change a culture. However, I can tell you that the personalities of pilots and doctors are not all that different, and if it can happen in the aviation industry, it can certainly happen in the healthcare industry.
Gregg A. Bendrick
Edwards Air Force Base
The writer is chief medical officer at the NASA Dryden Flight Research Center.
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