Learning from aviation safety: a call for formal "readbacks" in surgery

Excerpt

The first fatal airplane crash in history occurred exactly 100 years ago, on September 17, 1908, when Army lieutenant Thomas Selfridge died in a failed flight attempt with the aviation pioneer Orville Wright. Since that time, aviation safety standards have significantly improved. Currently, the risk for an American dying in an airplane crash is about 1:500,000, compared to a 1:20,000 chance of dying in a car accident. In the field of medicine, it was not until the shocking report by the Institute of Medicine in 1999 revealed that 100,000's of patients die in the United States every year as a consequence of medical errors [1], when we began to realize that there is something "wrong with the system". While this unacceptably high number has been chronically underrated in public recognition, an extrapolation of these statistics to professional aviation equals to about 200 jumbo jet crashes per year, or one 747 crash every other day. This dramatic insight led to the design of the "100,000 lives campaign" by the Institute for Healthcare Improvement in 2004 [2]. By 2006, the campaign had surpassed its initial goal by saving more than 120,000 lives through the implementation of increased patient safety standards and algorithms [2]. These include the recent implementation of a standardized surgical "time-out" to ensure the correct patient identity and correct procedure performed at the correct surgical site [3]. In addition, the implementation of formal, structured perioperative briefings in the operating room have been shown to significantly reduce the incidence of wrong site surgeries [4]. …