Going in the wrong direction


Here are some comments (some paraphrased) and suggestions made on a blog about adapting the Aviation Safety Reporting System to reduce the rate of medical errors.

Incident reporting provides “no useful information about the true frequency of errors in an institution.” It’s too expensive, it takes too much time. There’s too much data. We should only report errors that cause temporary or serious harm.

These comments were made by Robert M. Wachter, MD. From his blog’s bio …

 “He has published 200 articles and 6 books in the fields of quality, safety, and health policy. He is also a national leader in the fields of patient safety and healthcare quality. He is editor of AHRQ WebM&M, a case-based patient safety journal on the Web, and AHRQ Patient Safety Network, the leading federal patient safety portal.”

There are two ways to reduce the rate of medical errors.

  1. Lower the probability of errors that have not yet occurred
  2. Lower the rate of errors that have occurred.

The Aviation Safety Reporting System is an example of tackling #2.

Many (most) errors do not directly cause harm – they have the potential to cause harm. This can be understood be mapping out each medical procedure. To suggest to not report all errors will shortchange the system.

The most important errors receive focus by using a Pareto chart or table. The fastest way to reduce error rates relies on a suitable ranking system.

All of this takes time, training, and commitment.

Some successful medical examples: anesthesiology improvements in the 70s 80s (1). The recent reduction of infections in placing central lines (2).

Dr. Wachter is going in the wrong direction.


  1. Cooper JB, Newbower RS, Long CD, McPeek B: Preventable anesthesia mishaps: A study of human factors. ANESTHESIOLOGY 1978; 49:399-406. An online version of Paper 5 can be found at http://qshc.bmj.com/content/vol11/issue3/#CLASSIC_PAPERS
  2. Pronovost P. et al. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. N Engl J Med 2006;355:2725-32

PS – A commentator who agrees with Dr. Wachter offers a standard bit of resistance to using the Aviation Safety Reporting System in medicine – We’re different – medicine is more complicated.


One Response to Going in the wrong direction

  1. […] by Dr. Peter Pronovost has not been adopted by all hospitals. Dr. Wachter, with whom I have disagreed in the past (one of several examples) suggests that lack of charisma is responsible. That is, Dr. […]

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