7 Days in July

On the 17th July Malaysian Airlines MH17 crashed in Ukraine, all 298 people aboard were killed, on the 23rd July, Transasia Airways, GE222 crashed on landing in Taiwan in bad weather with 48 fatalities and on the 24th July, Air Algerie, AH 5017 crashed in Mali, N Africa killing all 116 on board. A total of 462 deaths globally.

This was truly a disastrous week for aviation and all of us who work with the airlines (see sister magazine CAT) felt almost offended that three accidents in a week could possibly happen, even though MH17 was shot down and AH5017 possibly the result of a terrorist attack, i.e. two crashes were to an extent possible to class as unavoidable or at least beyond the control of the airlines.

It was last November in Tatarstan that we recorded the last fatal accident in commercial aviation (globally) when 48 perished. Four years since the last fatal airline accident in the USA.

At all three sites, governments, airplane manufacturers and air accident investigators are attempting to find out what happened, to learn from any mistakes and the resulting recommendations, whatever they are, will be broadcast to the global airline community and acted upon. You as ‘joe public’ could have known about each accident within minutes due to the heavy press coverage, even though it is thought that only one US national was lost.

Also on the 17th July, a Senate Hearing on Patient Safety convened with the subtitle ‘More than one thousand preventable deaths per day is too many: The need to improve patient safety.’ http://www.help.senate.gov/hearings/hearing/?id=478e8a35-5056-a032-52f8-a65f8bd0e5ef

To make the obvious comparison; three aircraft go down in one week killing 462, during the same week, US healthcare was responsible for roughly 7000 deaths or pro rata the equivalent of just over 15 similar aircraft. We have no count of those not fatally injured by healthcare.

Though a ‘disastrous week’ for aviation this was not a ‘disastrous week’ for healthcare, just another week much like the last, despite a 15 year effort to improve patient safety. Yet no paper reported, no TV station commented and hardly any healthcare outlets responded. This is not surprising as the last thing patients need is to be anymore frightened of hospitals than they already are. None of us wants the reputation of the healthcare industry to suffer and the status of the profession to fall any further. If this was reported on, as are airline accidents of any type, the effect would be truly disastrous.

Can 2014 be, to quote Churchill, ‘the end of the beginning’ in the patient safety effort? It would be true to say, as Dr. Peter Pronovost did in the Senate Q&A, that we count many more patients deaths as avoidable today than we did some years ago, because we now appreciate that they are avoidable but adds we have not appreciably moved the needle of patient care over that fifteen year period.

That is progress of a sort. Two other quotes, among many powerful statements, stand out and are paraphrased here.

First: If I make an improvement in treatment in my hospital it will stay within these four walls because there is no mechanism to tell other hospitals.

Second: There are 300 hospitals in the US with a CLABSI rate ten times the average, and we know how to fix this.

The first point is difficult to address with regulation and legal issues acting against the best interests of future patients, hospitals and the country but it must be addressed if we are to take advantage of the excellent work that is going on. As an example see the ACS Tennessee study elsewhere in this publication.

On the second point can we simply expect those 300 hospitals, not to mention those thousands with simply a worse than average infection rate, to adopt the best practices outlined by Dr. Pronovost and his team and train their people to put things right very quickly? If they do not, after being given the opportunity and reasonable time, perhaps it is time to make their details available in the press so that patients can avoid ‘avoidable harm.’ (See Editor’s Comment p.3)