Have we gone too far in translating ideas from aviation to patient safety? No

To paraphrase James Carville, 'It's the analogy, stupid'. The issue
is not going too far or not far enough, it is that the aviation industry
provides a limited analogy for healthcare(1). Health care is a high risk
industry for staff and patients alike. There is no doubt that there are
other potentially high risk industries that have achieved enviable levels
of operational safety, and yes, we can learn from them. And certainly, the
impact of safety failures in aviation affect pilots and passengers alike,
increasing the incentives for good practices. But there is more to it than
that.

In a recent article in the Harvard Business review(2), Groysberg,
Hill and Johnson draw attention to the different operating styles within
the armed forces. They describe how in the Air Force and the Navy, many
day-to-day operations involve very closely coupled, extended, sequences
that need to follow predetermined standard operating procedures if they
are to be done successfully and safely. An error in any one step has
immediate repercussions all along the tightly linked sequence. Those kinds
of sequences are amenable to, and require, constant rehearsal, and a
preoccupation with following standard operations. Flexibility is traded
against safety.

Certainly there are aspects of patient care in fields such as
anesthesia that have similar characteristics.
But Groysberg, Hill and Johnson contrast this with the operating structure
of the Marines, which is essentially modular in nature, with
interdependent, largely autonomous units within units working in a
coordinated but flexible manner to achieve the goals set by the commanders
for the mission. They quote the military aphorism 'No plan survives first
contact with the enemy'. This could easily be replaced with not treatment
plan survives first contact with the elderly patient with multiple primary
conditions and comorbidities.

Tightly linked, rehearsable, checklistable, sequences in health care
are relatively uncommon in comparison to care delivered by a complex inter
-action of more or less well coordinated modular groups of nurses within
wards, doctors within teams, teams within units, units within
institutions, and institutions within communities. This is especially
relevant for the health care we are providing now to our aging
populations, a task that will only increase. So maybe the next step in
patient safety is to move from airplanes to thinking about sending in the
marines?

References

1 Gaba DM. Have we gone too far in translating ideas from aviation to
patient safety? No BMJ 2011; 342:c7310

2 Groysberg B, Hill A, Johnson T. Which of these people is your future
CEO? The different ways military experience prepares managers for
leadership HBR Nov 2010