Acting as if the Patient was Your Loved One or Just Checking Boxes?

We have made good strides in making healthcare safer at GBMC, but I am concerned that some of us are still where commercial aviation was in our country in 1987. Students in patient safety are often directed to commercial aviation for learning on how to make our care safer. After all, there has not been one death on a commercial plane in the US in 5 years…but it wasn’t always that way. I remember a horrible airline disaster from Detroit, Michigan. I lived with my family in Toledo, Ohio at the time and we often flew out of Detroit. Let me give you a brief version of what happened that I have taken from the National Transportation Safety Board official report that you can find online: http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR88-05.pdf

I also found two youtube clips that are recreations of the accident. http://www.youtube.com/watch?v=dgPYY4pAKao and http://www.youtube.com/watch?v=XKTQvIVXL7Y.

At about 8:46 PM on August 16, 1987, Northwest Airlines flight 255 crashed shortly after taking off from runway 3 center at the Detroit Metropolitan Wayne County Airport, in Romulus, Michigan. Flight 255, a McDonnell Douglas DC-9-82, was a regularly scheduled passenger flight and was en route to Phoenix, Arizona.

According to witnesses, flight 255 began its takeoff rotation about 1,200 to 1,500 feet from the end of the runway and lifted off near the end of the runway. After liftoff, the wings of the airplane rolled to the left and the right about 35” in each direction. The airplane collided with obstacles northeast of the runway when the left wing struck a light pole located 2,760 feet beyond the end of the runway. Thereafter the airplane struck other light poles, the roof of a rental car facility, and then the ground. It continued to slide along a path aligned generally with the extended centerline of the takeoff runway. The airplane broke up as it slid across the ground and post impact fires erupted along the wreckage path. Three occupied vehicles on a road adjacent to the airport and numerous vacant vehicles in a rental car parking lot along the airplane’s path were

destroyed by impact forces and/or fire. Of the persons on board flight 255, 148 passengers and 6 crewmembers were killed; 1 passenger, a 4-year-old child, was injured seriously. On the ground, two persons were killed, one person was injured seriously, and four persons suffered minor injuries.

Later in the report, one can read: The National Transportation Safety Board determines that the probable cause of the accident was the flightcrew’s failure to use the taxi checklist to ensure that the flaps and slats were extended for takeoff.

You see, prior to that time, airline pilots were revered as smart, brave, independent sorts, who were well-trained and could overcome any obstacle put in their way. In the 1970’s and 1980’s, however, as the study of airline mishaps became done in a standardized way, experts saw that often crashes were the result of these smart, well-trained people getting distracted or just plain forgetting to do something that then led to the catastrophe. The planes themselves were getting more complicated and there was a lot to remember. So, the Federal Aviation Administration began working with the airlines to create checklists that the pilots and co-pilots were told that they had to do prior to starting the engines, prior to leaving the gate, and prior to takeoff. What do you think the pilots initial reaction was? My reading tells me that many thought that checklists were an insult to their training and experience. A common reaction was: “This is stupid!  I have never forgotten to configure the wing flaps safely for take-off. These stupid regulators are wasting our time!” The NTSB’s review of the cockpit voice recording documented that the pilot and co-pilot only did some parts of the checklist and they did not do it in the manner prescribed. It appears that they were just “checking a box” and not understanding the reason why the checklist needed to be done. The NTSB also concluded that they and some other pilots had been doing the checklists in a cursory fashion routinely. The NTSB report quoted from the Northwest Airlines procedure manual:

During all ground operations it is the Captain’s responsibility to call for all appropriate checklists. . Giving consideration to other required crewmember duties and allowing for adequate time for completion. The First Officer will query the Captain if there is abnormal delay in the call for any checklist. The checklist items will be read in a loud clear voice and the proper response will be equally clear and understandable. Where a challenge and response item is performed, a response is required from another crewmember, the crewmember reading the checklist will repeat the challenge if necessary until the proper response is provided. Undue haste in the execution of any checklist is neither necessary nor desirable.

The checklist tools were well designed and would have prevented 156 deaths that day if the standard work had been done but the prevailing culture of cockpit crews killed them that day.

In the last couple of weeks, we have had a number of events at GBMC where I am concerned that some members of our family are “just checking the boxes”. They are acting as if things like our universal protocol and the use of the timeout before any procedure are “not really necessary”. We must find a way to get into the hearts and minds of all of these people and get them to realize the absolute necessity of not only doing our checks as they are designed, but also of understanding the reason why we are doing it. I and other leaders must spend more time listening to them and coaching them.

Just like the Northwest Airlines manual said in 1987, it is the Captain’s responsibility to call for all appropriate checklists and to see that they are done appropriately and in the spirit of protecting the patient. In medical care, the Captain is most often the physician.

The physician must take the lead, but the co-pilots, our nurses, technicians, and everyone else involved, must play a role and demand that the safety procedure be followed. I and the other senior leaders of GBMC will back all physicians and nurses that stand up to assure that our safety procedures are followed. If your daughter was the patient, you would stand for nothing else. We will be in action on this until we see that the culture has definitely changed for all and then we will stay vigilant. If anyone needs help with this please contact me.