A hero’s per­spec­tive

Sul­len­berger gives new con­text to well-worn pa­tient-safety points

Modern Healthcare - - Opinions Editorials -

As se­ri­ous as the topic of pa­tient safety is, I can’t help but roll my eyes ev­ery time I hear a guest speaker at a health­care con­fer­ence or ban­quet say “it’s like a jumbo jet crash­ing ev­ery day for a year” when they’re putting into per­spec­tive how many peo­ple die an­nu­ally from med­i­cal er­rors. I’m not sure who gets the credit for the overused anal­ogy, but I’ve been hear­ing it for more than 10 years, ever since the In­sti­tute of Medicine re­leased its famed To

Err is Hu­man re­port in 1999. I heard the jet crash anal­ogy again two weeks ago in At­lanta when I was cov­er­ing the an­nual HIMSS con­fer­ence and ex­hi­bi­tion for Live@HIMSS, our daily elec­tronic news­let­ter from the show. This time when I heard it, I didn’t roll my eyes. That’s be­cause the words came out of the mouth of newly re­tired US Air­ways Capt. Ch­es­ley “Sully” Sul­len­berger, who gave the clos­ing key­note ad­dress at the con­fer­ence.

Sul­len­berger, of course, is cred­ited with sav­ing the lives of all 155 pas­sen­gers and crew mem­bers when he landed his crip­pled air­liner on New York’s Hud­son River on Jan. 15, 2009. For Sul­len­berger, the anal­ogy wasn’t a catch­phrase but rather a po­ten­tial out­come he lived with for 30 years as a com­mer­cial air­line pi­lot if he didn’t do his job per­fectly each and ev­ery time.

In his nearly hour­long pre­sen­ta­tion, Sul­len­berger preached about all the safety lessons learned in avi­a­tion that could be ap­plied in the health­care in­dus­try to re­duce med­i­cal er­rors. What im­pressed me most was that his pre­sen­ta­tion was custom-writ­ten for the oc­ca­sion. Sul­len­berger didn’t show up with a canned mo­ti­va­tional speech. He cared enough to ar­rive in At­lanta with a well-crafted speech com­par­ing and con­trast­ing the safety is­sues, cul­ture and strate­gies be­tween two in­dus­tries: avi­a­tion and health­care.

I have no doubt that Sul­len­berger had some help in pre­par­ing the speech. It would be im­pos­si­ble for him to have first­hand knowl­edge of some of the anec­dotes he cited from in­di­vid­ual hos­pi­tals and physi­cians. But that’s be­side the point. Sul­len­berger, with a lit­tle as­sis­tance, tai­lored his talk to the sev­eral thou­sand HIMSS at­ten­dees who stayed to the end of the four-day con­fab to hear him speak.

He sim­ply could have re­told the story of the land­ing on the river, and the crowd would have walked away happy. Rather, Sul­len­berger didn’t take their at­ten­dance for granted, and he spoke to them about their pro­fes­sion.

He worked in a num­ber of health­care in­for­ma­tion tech­nol­ogy ref­er­ences, such as the use of “de-iden­ti­fied” safety data. He said the 1977 col­li­sion be­tween two Boe­ing 747 jets at an air­port in the Ca­nary Is­lands that killed 583 peo­ple was “the air­line in­dus­try’s IOM re­port” that launched the mod­ern avi­a­tion-safety move­ment. And he thanked a New York hospi­tal for sneak­ing him, his first of­fi­cer and two flight at­ten­dants into the room of a third flight at­ten­dant who was in­jured in the crash land­ing and safe­guard­ing their pri­vacy.

Un­like air­plane crashes, med­i­cal er­rors hap­pen one at a time in in­di­vid­ual hospi­tal rooms and physi­cian offices and, there­fore, don’t re­ceive the same amount of pub­lic at­ten­tion, Sul­len­berger ex­plained. “You need to start think­ing of th­ese med­i­cal mishaps not as in­evitable but as unimag­in­able,” he said. “You could make the prac­tice of medicine as safe as avi­a­tion has be­come.”

Af­ter his for­mal re­marks, Sul­len­berger calmly fielded seven ques­tions—and in some cases, long-winded state­ments—from mem­bers of the au­di­ence. One was from a sob­bing woman who said a med­i­cal er­ror led to the death of her mother. In front of thou­sands, a pa­tient Sul­len­berger told her he was sorry for her loss. He later quipped, “I never did any pub­lic speak­ing be­fore Jan. 15, and frankly I didn’t want to.”

Sul­len­berger is the real deal. He could be the pa­tient-safety mes­siah every­one has been wait­ing for.



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