StATS: A plea for open-mindedness (created 2006-11-02).

Most people that I work with are quite open minded, but I do encounter, from time to time, someone who is resistant to ideas that originate from outside the sphere of medicine. In particular, some individuals are almost cynical about the application of quality control in health care. The attitude seems to be something like this:

Quality control is an approach that works on assembly lines. I am a doctor not a factory worker, and my patients are not products on an assembly line.

That's a fair statement. Patients are not widgets, and it is a mistake to treat them the same way. But it's also a mistake to think that we can't learn from how other people have approached problems that do indeed bear some semblance of similarity to the problems that you face.

Let me mention a slightly different area where healthcare professionals are indeed listening to and learning from outsiders. Patient safety is a very important issue in hospitals. Healthcare professionals recognize they make mistakes and their patients sometimes suffer from those mistakes. There are numerous well publicized examples of this, such as the following tragic report:

Boy, 6, killed in MRI accident. The Journal News. Melissa Klein and Oliver W. Prichard. (Original publication: July 31, 2001) VALHALLA — A 6-year-old boy died two days after he was smashed in the head by a metal oxygen canister that was pulled by magnetic force into the MRI machine where he was being examined, Westchester Medical Center officials said yesterday. An unidentified hospital employee brought the oxygen tank within reach of the 10-ton magnet's field, and it shot through the air to the center of the machine, the hospital said. (Source:

Or this one:

Doctor mistakenly amputates wrong foot. Dec 28, 2004 (TUXTLA GUTIERREZ, Mexico) - A doctor at a public hospital in southern Mexico mistakenly amputated the right leg of an elderly patient who had sought treatment for an infection in his left foot, the patient's family announced Sunday. Seeking treatment for a foot wound aggravated by diabetes, Alberto Lopez, 74, was admitted to a Social Security Institute hospital in Tuxtla Gutierrez, 430 miles south of Mexico City, and underwent surgery on Friday. But the patient emerged from surgery without a right leg and still suffering from the original infection according to family members who filed a complaint Sunday with the state attorney general's office and a national medical arbitration commission. (Source:

Anecdotes like this produce a strong emotional impact among healthcare professionals and in the general public. There's also the recognition among healthcare professionals that many preventable deaths and illnesses in our hospitals go unrecognized, and simple interventions like regular handwashing are ignored. So who have the doctors and nurses and other medical professionals turned to for help with patient safety? The suprising answer is documented nicely in a recent newspaper article by Kate Murphy in the October 31, 2006 issue of the New York Times, What Pilots Can Teach Hospitals About Patient Safety. This article has a very strong lead.

Wearing scrubs and slouching in their chairs, the emergency room staff members, assembled for a patient-safety seminar, largely ignored the hospital’s chief executive while she made her opening remarks. They talked on their cellphones and got up to freshen their coffee or snag another danish. But the room became still and silent when an airline pilot who used to fly F-14 Tomcats for the Navy took the lectern. Handsome, upright and meticulously dressed, the pilot began by recounting how in 1977, a series of human errors caused two Boeing 747s to collide on a foggy runway in the Canary Islands, killing 583 people. Riveted, a surgeon gripped his pen with both hands as if he might break it, an anesthetist stopped maniacally chewing his gum, and a wide-eyed nurse bit her lip. An attention grabber, yes, but what does an airplane crash have to do with patient safety?

Apparently some pretty important people in the healthcare industry do believe that there is a link

After the Canary Islands accident, NASA convened a panel to address aviation safety and came up with a program called Cockpit or Crew Resource Management. The Federal Aviation Administration requires that all pilots for commercial airlines and the military undergo the training. They learn, among other things, to recognize human limitations and the impact of fatigue, to identify and effectively communicate problems, to support and listen to team members, resolve conflicts, develop contingency plans and use all available resources to make decisions.

Recognizing the positive impact of the program on the aviation industry’s safety record, the Institute of Medicine in 2001 recommended similar training for health care workers. The National Academies, the Agency for Healthcare Research and Quality and the Institute for Healthcare Improvement also advocate the training, as well as the use of other aviation-inspired practices like pre- and post-operative briefings, simulator training, checklists, annual competency reviews and incident reporting systems.

So is there a commonality between landing an airplane at Heathrow and excising a gall bladder?

“The trend is not surprising given the similarities between health care and aviation,” said Dr. David M. Gaba, associate dean of immersive and simulation-based learning at the Stanford University School of Medicine in Palo Alto, Calif. “Both involve hours of boredom punctuated by moments of sheer terror,” he said. In addition to sometimes having to make life-and-death decisions in seconds, pilots and physicians also tend to be highly skilled, Type A personalities, who rely heavily on technology to do their jobs.

There are differences as well and the article points these out.

The definition of an error in health care, Professor Helmreich said, is “fuzzier” than in aviation, where it is easier to identify a “foul-up” and who was responsible. Health care providers’ fear of litigation and losing their medical licenses also hinders the honest reporting of mistakes, whereas aviators are often inoculated against punishment if they promptly report incidents to the authorities. Training programs developed by pilots without knowledge of health care realities can be “appallingly bad,” he said.

I believe that a respectful attitude couched in humility is the best approach for people who are advocating new approaches and people who are listening to those advocates. We can't force fit solutions from the outside that don't respect the unique aspects of healthcare, but neither can we pretend that healthcare is so unique that only an insider can make changes and suggestions for improvement.

If healthcare professionals can learn from pilots, there may even be a sliver of hope that they can learn from Statisticians.

This page was written by Steve Simon while working at Children's Mercy Hospital. Although I do not hold the copyright for this material, I am reproducing it here as a service, as it is no longer available on the Children's Mercy Hospital website. Need more information? I have a page with general help resources. You can also browse for pages similar to this one at Category: Quality control.