Health experts look to
airlines for way to cut errors

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By Helen Altonn
haltonn@starbulletin.com

The aviation industry's sanction-free safety reporting system might be a way to encourage reporting of medical errors, suggests a doctor who is a commercial pilot.

Robert Bonham, emergency physician at the Waianae Coast Comprehensive Health Center and FAA-certified flight instructor, described how the aviation model might be applied to health care at a recent conference at St. Francis Medical Center.

The Department of Veterans Affairs signed an agreement with NASA in May 2000 to create a patient safety reporting system at its medical facilities modeled after NASA's Aviation Safety Reporting System.

Hawaii hospitals also began looking to the aviation industry for solutions after a 1999 Institute of Medicine report estimated medical errors nationally kill up to 98,000 hospital patients annually.

The voluntary aviation error reporting system was established in 1975 between NASA and the Federal Aviation Administration.

All reports are confidential and those submitting them get what amounts to a "get out of jail free card," Bonham said.

Tweet Coleman, FAA Pacific representative, explained later that a crew member, traffic controller or even a passenger can file an incident report with NASA. "A prudent pilot that sent in a NASA report will call or write FAA and say, 'Yes, I made an error and filled out a NASA report,' and won't be sanctioned," he said. "One of these is permitted every five years."

For the first time in 20 years, American commercial aviation had no fatalities last year, Bonham said.

"Accidents are a chain, a progression of small errors that culminate in an accident," he said. About 30,000 reports of errors are being submitted annually to the FAA, which is catching small things and breaking the chain, he said.

Capt. David Chock, Aloha Airlines pilot trainer and evaluator, said aviation safety is continually being improved with advanced training and equipment and response to changes, such as increased congestion in the skies. Simulators are used to identify problems and take corrective action to reduce human errors, he said.

Dr. S.Y. Tan, director of St. Francis International Center for Healthcare Ethics, said anesthesia errors have been reduced through use of simulators for training, technological changes, development of practice guidelines and standards and creation of an Anesthesia Patient Safety Foundation.

Death rates dropped from two per 10,000 patients in the early 1980s to one per 200,000 to 300,000 anesthetics administered currently, he said. "Malpractice premiums for anesthesiologists have tumbled as a result."

Tan said a medical error reporting system is needed that provides immunity, similar to the aviation safety system.

The Institute of Medicine has recommended a nationwide reporting system, but Tan said "it would be especially good if we could be leaders" with a state system.

Dr. Susan Tolle, director of the Center for Ethics in Health Care, Oregon Health Science University, noted Hawaii has "a very polite, nonconfrontational, saving-face culture," which makes it more difficult to point out medical errors.