Patient Safety Tip of the Week

August 28, 2007    

Lessons Learned from Transportation Accidents


We pointed out in our May 15, 2007 Tip of the Week that important lessons from other industries can be applied in healthcare regarding patient safety. Accidents in the airline and transportation industries have many analogies to adverse incidents in healthcare. Another good example is the 1996 ValuJet fire and crash in the Everglades (NTSB report).



Basically, the fatal crash followed a fire in the cargo compartment that was triggered by unexpended chemical oxygen generator canisters. Such canisters were known to be capable of producing fires, both because they generate large amounts of heat and then supply oxygen capable of feeding the fire. Procedures called for not shipping such canisters unless they had locking caps or their contents had been completely expended.



The major issues had to do with the nature of the maintencance of planes and problems with communications. ValuJet was a relatively new airline that was expanding rapidly. One of its cost control strategies was to outsource some of its plane maintenance, a practice allowed by the FAA as long as the same policies and procedures were followed by the subcontractor that would apply to in-house maintenance. The airline outsourcing is also responsible for oversight and supervision of the subcontractor’s work. The company doing the outsourced maintenance, SabreTech, also had both its own full-time maintenance personnel and hired other temporary personnel. The latter did not receive the same inservice/training on various policies & procedures that the full-time personnel received. SabreTech also apparently did not have in stock the locking caps that were required to disable the canisters.



In addition to the financial pressures that led the airline and the maintenance organization to use subcontractors and temporary personnel, there was an additional pressure created by the contractual obligation of the subcontract to turn the airplane over in a specified time period or face a financial penalty. So some of the technicians were working extensive overtime in attempt to meet the time constraints.



They were also functioning in “multi-operator’ teams, where work begun by one technician might be eventually completed by another technician. Hence, communication during handoffs was a problem. In some cases, the “work cards” were signed as though a step (the expending of the contents) was completed, assuming that someone else had or would complete that task. And color-coded labels that should have identified the canisters as hazardous were inappropriately used, resulting in personnel in shipping/receiving to be unaware they had materials that should not be placed aboard a plane. And in some cases the only communication that took place with the shipping/receiving personnel was via those labels. The latter eventually cleared the canisters to be loaded on the ill-fated airplane.



Additionally, the parent airline did have supervisory personnel assigned to the subcontractor but they worked only in the daytime whereas much of the maintenance activities were done at night.



Sound familiar? Most of these issues are faced by healthcare facilities on a regular basis. Financial pressures often lead to use of part-time or temporary personnel rather than full-time personnel. So one needs to be concerned about proper training/inservicing of those personnel and ensure that the communications during the resulting increased number of handoffs will be appropriately managed. In some cases, the “savings” achieved by use of part-time or temporary personnel may be short-sighted. Additionally, it is difficult for such temporary personnel to become part of a “culture of safety” one needs to develop in a healthcare facility. But if and when you do need to use temporary or part-time personnel, make sure that they have been appropriately trained for all the procedures in their area of work.



Teaching facilities also need to take this into account when housestaff are rotating from one hospital to another because they are similar to the temporary personnel in that regard.



The color tag issue is also an important one. In healthcare we often use color coding as a useful patient safety measure. Nevertheless, everyone needs to understand what the color coding means. When a facility uses a color code that is not an industry-wide accepted standard, the “temporary” personnel may not be familiar with it and may misinterpret its significance.



And the communications/handoffs/multi-operator team issues abound in healthcare facilities. And if you are auditing the quality of handoffs in some fashion, make sure you audit a sample of all handoffs, not just the daytime ones (particularly since more handoffs probably occur during the evening and night hours).



Once again, lessons learned from other industries may be extremely valuable in patient safety activities. We’ll have some other examples in future Tips of the Week.






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