Error can be understood as a matter of negligence, a willful disregard for standards. Or it can be understood in the context of normal human frailty. In fact, the opposite is true, says Dr. Donald Berwick, president of the Institute for Healthcare Improvement, a Boston research center. The vast majority of medical mistakes are committed not by bad apples, he says, but by good doctors trying to do the right thing, working under conditions that do not account for the fact that they are human. Aviation has done precisely this over the past two decades.
Simulators teach airline crews teamwork.
For the past several years, Dr. Helmreich has been working to bring these same techniques of 'crew resources management' to health care. Dr. Leonard, who is among Dr. Helmreich's disciples, recently visited Southwest Airlines to observe a pilot training session. But just as important as training, the experts say, is a change in culture that makes it permissible to talk about mistakes. When a plane accident results in death or serious injury, the National Transportation Safety Board investigates. When a hospital patient dies, doctors convene what is known as an 'M and M' conference, for morbidity and mortality, to analyze the death and discuss how it might have been prevented.