There are parallels in other industries. “Airframe, published in 1995 (Alfred A. Knopf) by the genius (and unfortunately late) medical
writer Michael Crichton, discusses a disaster on a trans-Pacific flight. The industry tries to find a scapegoat,
but instead of the obvious pilot error (the captain let his son fly the plane while
he left the cockpit for a necessary stop), it was found that the plane wing malfunctioned
in turbulence because it had a defective bolt made offshore, the company saved money,
the wing malfunctioned, the union had a stake in the manufacture, and the list goes
This is a great novel that shows that most errors ─ manufacture or medical ─ have
several leading factors.
Brilli, McClead, et al, show a diagram in Moss and Adams’ , taken from James Reason’s
1997 book . It depicts a disastrous chain of preventable events with a model showing
several parallel slices of Swiss cheese.
If the holes line up, each supporting event leads up to a disaster. Any repositioning
of any of the slices would prevent the holes from lining up and stop the process.
What if the new intern had been directly supervised? Such is quality improvement.
Also worthy of mention is the work of Dr. Marc de Leval, a cardiac surgeon at Great Ormond Street Hospital in London, who was getting poor results with his heart surgery patients: They left
the operating room in fine condition, but several died later.
Instead of continuing without pause, he recognized a problem. Coincidentally while
watching a car race, he was impressed with the coordination of pit-stop race crews and their quiet efficiency.
He had them visit his facility, and they were appalled at the inefficiency of ICU
handoffs and poor coordination of care from one station to the next.
He retooled his team against their model, went to other successful centers and learned
from their approaches, and his results became spectacular. This was before we had
a term for quality improvement and patient safety.
One inescapable conclusion is that ALL hospitals must have leadership that understands
how to develop and implement meaningful change for quality improvement in medicine.
Change is not easy, but if we do not recognize (i.e., ignore) and implement a safety
environment, the unacceptable preventable mortalities will continue.