February 8, 2010 | Mark Paradies

Monday Accident & Lessons Learned: Hospitals Adopt a Best Practice from 1935

In 1935, the most experienced test pilot crashed the most advanced airplane, the Boeing 299. The papers said it was too much plane for one man to fly. As it turns out, it wasn’t “too complicated” – rather, there was just too much to remember. Too many controls to remember to set. Set something wrong (or forget to set it) and the plane would not fly. Flying had grown too complex to depend on a person’s memory.

The answer was simple: a checklist. Actually, four checklists. At first, pilots resisted. But it’s hard to argue with the evidence that checklists helped avoid common errors and keep planes from crashing. Now, aviation checklists are a staple of the professional pilot.

I would argue that medicine became too complex to rely on doctors’ or nurses’ memories long ago. Hospitals must adopt the best practices that are the staple of high-performing organizations (for example, aviation or nuclear power). It is far past the time that standard practices and checklists should have been adopted to stop sentinel events, especially when a twelve-year study published in the January 2009 issue of the New England Journal of Medicine shows a 40% reduction in accidental deaths when hospitals use checklists.

That’s just one of the best practices that should be adopted immediately to improve performance in the healthcare industry. Another? TapRooT® Root Cause Analysis.

Root Cause Analysis
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