April 1, 2002

Nobody likes close calls - least of all pilots and doctors - but the aviation industry has turned them into a tool for improving safety; and the health care industry can do the same.

That was the message delivered to Health Center faculty and staff earlier this month by physician, former astronaut and pilot, James Bagian.

Bagian knows a thing or two about close calls. He told a story about a time he and a group of reservists on a nighttime exercise were about to jump from a plane. He called it off with 15 seconds to spare because something seemed amiss. It turned out they would have lost the plane, and probably some lives, if the jump had occurred. As it was, the next night they tried it again, and everything went smoothly.

"That was a close call, but nobody got mad at me for calling off the jump. Nobody wasted time looking for someone to blame," said Bagian. "That's the difference between the aviation industry and health care," said Bagian. "And until health care gets rid of the name-and-blame approach to patient safety, it will continue to be a problem."

Bagian shared his views with the faculty and staff at a presentation that was part of the Health Center's Business of Medicine seminar series and part of the Health Center's ongoing program to raise awareness of patient safety. "Dr. Bagian is a national leader in the push for safety in health care," said Robert Kozol, chief of staff and organizer of the seminar series. "It is a top priority for us so we keep raising awareness of the issue."

It's generally accepted that patient safety is a major problem in health care, according to Bagian: "There may be arguments about the precise number of errors or adverse events, but the number is still huge and it is enough for us to be concerned about."

Bagian has brought some of the habits and culture of the aviation industry to his new position as director of the Department of Veterans Affairs' National Patient Safety Center, in its effort to improve patient outcomes. In particular, he has borrowed the industry's close call reporting system and, in turn, the agency has seen dramatic increases in the reported number of close calls and an equally dramatic improvement in patient safety. "Close calls are incidents where something almost goes wrong. You want to know about close calls, because they tell you about the vulnerabilities in your system. They are things that you can fix," said Bagian. "Close calls happen 20 to 600 times more often than the event they are the harbinger of. That means you have at least 20 chances to fix them before there is a tragedy.

"To learn about close calls, you have to have voluntary reporting," said Bagian. "But you cannot make people report themselves if they're afraid they're going to be unjustly punished. You need to remove their fear before a true self reporting system will operate."

Error prevention also requires clear and unfettered communication at all levels, added Bagian. The lowest-ranking employee should feel comfortable talking to, and questioning, the highest-ranking one. "That means a dietary aide who notices something wrong with a patient should feel comfortable alerting the nurse or the doctor. And the response should not be 'Just deliver the trays,' or 'Where did you get your health care degree?'"

He pointed out that airplane pilots go over a pre-flight checklist before every flight. They talk about their work as a team. That doesn't happen routinely in health care, where individuals tend to think it's enough if they do their own job really well, Bagian said. "It's not enough to be perfect on your own," he added. "You have to have a system in place that helps people do the right thing."