Friday, April 5, 2013

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:
I also found two youtube clips that are recreations of the accident. and

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. 


  1. I remember this accident, especially because of the 4-year-old survivor. I saw online that she moved to Alabama with relatives and later graduated from the University of Alabama. I guess she's 30 now. Whenever I'm flying, I always give myself a pep talk in the car on the way to BWI, telling myself "you're more likely to be in an accident getting to the airport than being in the plane." So far, so good! Lately I've heard about some patient safety problems at GBMC. In my opinion, the two biggest issues in guaranteeing patient safety that we face as health care providers are: 1. Distractions, 2. Assumptions. We have to help each other in our daily work so that we're always putting the patient first. The play "Bedside Manners" at Schwartz Rounds last week really showed that. In a culture where belitting others is the norm, no patient is safe. Doctors especially need to get over feeling like their authority is being challenged when a nurse or care manager asks a simple question. Maybe we didn't go to med school, but we're darned smart, too!

  2. Thanks, Anonymous. I think of that little girl, now a woman who has only her memories of her parents as a 4 year old

    I agree with you that we have frequent distractions and we must be preoccupied with failure. This means that we must consciously realize that stress and abnormal situations make error more likely. If we think this way, we will change our culture and we will do our checks correctly and in the correct spirit. Our patients will benefit from this.

    Schwartz Rounds is a great forum but not many actively practicing doctors and nurses get to it. We need this discussed in as many venues by as many members of our family as we can get to discuss it

    The doctor is the captain of the team but he or she must look out for and respect the opinions of all members of the team.

  3. Do we "just check the boxes"? Let's view this from a different perspective. The number of boxes that need to be checked is growing rapidly. It appears that administrators sometimes implement initiatives that unnecessarily increase the amount of mandatory documentation- we are getting to the point where we are losing sight of the basics. What is really important and appropriate?

    A prime example- There is a new mandatory "history of attempted suicide" assessment required on all patients. Imagine asking the parents of a 2 year old if their child has a history of attempted suicide or the same question of a grandmother that is here for foot surgery. When nurses are bogged down with boxes and boxes like this that require checking it is easy to see how the crucial questions get over-looked.

    Do we need to revisit what is important to each patient's individual needs? If checklists are less all-inclusive but more pertinent would there be better compliance and ultimately safer care?

    1. Thanks very much, Anonymous. I am with you. I am very concerned that in the area of documentation we do have too many boxes. I know that our Nursing User Team is currently looking at "all the boxes" to see if some can be eliminated. Please give them your ideas.

  4. So what are the suggestions? Many times a nurse will make a recommendation and the residents, internist; as well as, surgeons nod and move on making the team feel worthless. There is a sense of hierchy among physicians at GBMC. "Do not question me I am the Captain of the Ship" We as nurses take care of physician's patients 24/7 a physician may see his or her patient maybe 20-30 minuites when rounding. Many time physicians do not return a nurses call which becomes very concerning. When a physician is called during the evening or night we (nurses) know what to expect when and if the call is returned, an unhappy physician becasue we (nurse) interrupted their dinner or woke them up. It becomes very frustrating because we (nurses)follow our SBAR check off list, but the captain does not follow through in the cock-pit, the buck is passed! Changing the culture is difficult in any health care setting especially with what health care is faced with today. It is very important though to treat each and every patients as "if they were our loved ones" BUT this change needs to occur from the top down. Physicians at GBMC need some sensitivity training and physicians need to know what is expected of them. However, there is this fear not only at GBMC, let's make the docs as happy as we can because if not they will take their patients elsewhere. Airline personnel work together so their passengers use their airlines each and every time a person travels. Airlines listen to all personnel to better the environment. When is the last time a hospital team that includes RNs, techs, etc. had the opportunity for a round robin with a physician group??? Is this heard of for physicians to hear first hand from the people who are caring for his or her patients? Wouldn't it be wonderful if there was a waiting list to get into GBMC. Even though I am anonymous you have my support!! I would like to challenge you as our Captain to get the physicians on board in making GBMC a safe, caring, and friendly place to be.

    1. Thanks very much, Anonymous. The Physicians have to be in the lead on this. I said this to our Department Chairs and other members of the Medical Board on Tuesday evening of this week. Most of our physicians do get it and are working very well with the rest of their teammates but some are not. I will work with them and our leaders to improve our culture of safety.

      I assume that you work on an inpatient unit. You will be having a feedback session soon on your unit's culture of safety survey. Please speak up at that meeting and make the case that you made here. Thank you.


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