Patient Safety: Insights from the Aviation Sector

Dr Lekh Jung Thapa

“The aviation industry has achieved a remarkable safety record with a 1 in a million chance of harm, while healthcare still sees a 1 in 300 chance of patient harm during care.”

Having traveled frequently by air over the past decade, I have come to appreciate the rigorous protocols that airline personnel implement to ensure the safety of passengers. A notable practice is the use of a checklist during the boarding process for domestic and international flights. This checklist encompasses a detailed array of items that must be thoroughly examined and confirmed prior to the aircraft’s departure, all aimed at safeguarding passenger safety. What stands out is the unwavering commitment of airline staff to adhere to these safety protocols. Regardless of how many times they perform these tasks, they approach them with the same diligence and focus, underscoring the aviation industry’s relentless dedication to ensuring passenger well-being. This meticulous attention to detail is vital in aviation safety, as even minor oversights can lead to dire consequences. As a frequent flyer, I recognize the importance of these safety measures and the role they play in facilitating a secure and pleasant travel experience. The dedication of airline personnel to passenger safety serves as a powerful reminder of the necessity of prioritizing safety in high-risk sectors, such as healthcare.

As a neurologist with extensive experience in Nepal, I have observed that the landscape of medical care in the country is complex, characterized by challenges at individual, provider, and national levels. On an individual level, the overwhelming influx of new clinical research can make it difficult for physicians to deliver optimal care to their patients. At the systemic level, hospitals face issues such as staffing shortages, lack of experts, limited access to appropriate medical technology, and the need for effective transitions between inpatient and outpatient services.

“Patient safety is about preventing harm, not just fixing mistakes. Healthcare needs a culture of learning and transparency, similar to aviation’s rigorous safety protocols.”

Nationally, Nepal’s healthcare system is often criticized for its inadequacies, compelling patients to navigate a complex network of healthcare providers in search of effective and affordable treatment. Despite the rapid evolution of the healthcare industry in Nepal, preventable adverse events (PAEs) that negatively impact patients like medication errors,¹ unsafe surgical procedures,² health care-associated infections,³ diagnostic errors, patient falls, pressure ulcers, patient misidentification, unsafe blood transfusion and venous thromboembolism remain alarmingly common. However, the comprehensive data on these issues are still lacking.⁴ This situation is exacerbated by a lack of transparency and limited accountability for errors that result in patient harm.

“In Nepal, preventable adverse events like medication errors, unsafe surgeries, and infections remain alarmingly common. We need more data and transparency to address these issues.”

While it is often said that “to err is human,” these mistakes can and should be avoided. Patient safety is fundamentally about preventing harm to patients. It emphasizes a care delivery system that not only prevents errors but also learns from them, grounded in a culture of safety that encompasses healthcare professionals, organizations, and patients alike. Despite significant advancements in medical technology and practices, patients harm continue to be a 14^th leading cause of morbidity and mortality globally. In contrast, the aviation industry has achieved remarkable safety records through systematic risk management and a robust safety culture. There is a 1 in a million chance of a person being harmed while travelling by plane. In comparison, there is a 1 in 300 chance of a patient being harmed during health care.⁵ This article examines the safety protocols employed in aviation, compares them with those in healthcare, discusses the limitations of current practices, and offers recommendations for improvement.

“Aviation’s success in minimizing accidents lies in its ‘Just Culture’—an environment where mistakes are openly reported and addressed, unlike the blame culture prevalent in healthcare.”

The Significance of Patient Safety

Patient safety is defined as the prevention of avoidable harm to patients and the minimization of risks associated with healthcare to an acceptable level.⁶ This broad concept encompasses various issues, including medication errors, surgical complications, healthcare-associated infections, and diagnostic mistakes. The World Health Organization (WHO) has underscored the importance of patient safety, identifying it as a critical component of quality healthcare. Research indicates that medical errors rank as the third leading cause of death in the United States, following heart disease and cancer.⁷ In low-to-middle income countries, as many as 4 in 100 people die from unsafe care.⁸ These alarming statistics highlight the urgent need for effective patient safety measures within healthcare environments.

Safety Protocols in Aviation:

The aviation sector is renowned for its unwavering commitment to safety, employing a variety of procedures and protocols that have significantly decreased the incidence of accidents and fatalities. According to the International Civil Aviation Organization (ICAO), the annual number of aviation accidents has shown a decreasing trend from 2019 to 2023. Notably, the number of fatalities associated with fatal accidents dropped significantly from 160 in 2022 to just 72 in 2023, marking the lowest fatality rate in the past five years.⁹ This significant improvement can be attributed to the aviation industry’s adoption of key safety procedures, which include:

• Culture of Safety: The aviation industry has cultivated a strong culture of safety that emphasizes transparency, communication, and continuous improvement. This culture encourages open dialogue about safety concerns and fosters an environment where personnel feel empowered to report issues without fear of retribution. They adopt the “Just Culture” approach, which is an environment where frontline workers are not penalized for actions, omissions, or decisions made within the scope of their experience and training. However, it does not tolerate gross negligence, intentional violations, or harmful behavior.
• Standard Operating Procedures (SOPs): Aviation relies heavily on standardized operating procedures that ensure consistency in operations. These SOPs are meticulously crafted and regularly updated to reflect best practices and lessons learned from past incidents.
• Training and Simulation: Continuous training and simulation exercises are integral to aviation safety. Personnel undergo rigorous training that includes regular simulations to prepare for various scenarios, ensuring they are well-equipped to handle emergencies.
• Incident Reporting and Investigation: The aviation industry has established robust incident reporting and investigation processes. Every incident is thoroughly examined to identify root causes and implement corrective actions, promoting a culture of learning and improvement.
• Regulatory Oversight: Aviation is subject to stringent regulatory oversight, with governing bodies enforcing uniform standards across the industry. This oversight ensures a consistent approach to safety and accountability.

“In low-to-middle-income countries, resource constraints and cultural barriers make it harder to implement patient safety measures, but learning from aviation’s success is essential.”

Comparing Aviation and Healthcare Safety Protocols

While the aviation sector has developed effective safety measures, healthcare often faces similar challenges. Here are some key comparisons:

• Cultural Differences: Aviation has cultivated a strong safety culture, whereas healthcare frequently struggles with a culture of blame. Medical errors often result in litigation and punitive measures, which can stifle open communication and discourage reporting. This fear of repercussions can lead to underreporting of incidents and a lack of transparency in healthcare settings.
• Standardization of Procedures: The healthcare sector lacks the same level of standardization seen in aviation. Different hospitals may implement varying protocols, leading to inconsistencies in patient care. The absence of universal checklists and SOPs can result in critical oversights. In contrast, aviation’s standardized procedures ensure that all personnel adhere to the same protocols, minimizing variability.
• Training and Education: Healthcare professionals receive varying degrees of training in patient safety. While some institutions prioritize safety training, others may not, resulting in gaps in knowledge and practice. In aviation, training is an ongoing process, with regular updates and simulations to maintain readiness.
• Incident Reporting and Investigation: Healthcare systems often have fragmented incident reporting processes. Unlike aviation, where incidents are rigorously investigated, healthcare may lack the same level of thoroughness, leading to missed opportunities for learning and improvement. The absence of a no-fault reporting system can further exacerbate this issue.
• Regulatory Framework: Healthcare regulation is often less centralized than in aviation. Different hospitals may operate under varying regulations, resulting in inconsistencies in safety practices. In aviation, regulatory bodies enforce uniform standards across the industry, ensuring a consistent approach to safety.

Limitations of Current Patient Safety Practices

Despite the recognition of patient safety as a critical concern, several limitations persist in current practices:

• Inadequate Reporting Systems: Many healthcare facilities lack comprehensive incident reporting systems, leading to underreporting of errors and missed opportunities for improvement.
• Fragmented Communication: Communication breakdowns among healthcare providers can result in critical information being lost, which can adversely affect patient outcomes.
• Limited Accountability: The absence of a culture of accountability can hinder efforts to address safety concerns and implement necessary changes.
• Resource Constraints: In lower and middle-income countries, limited resources can impede the implementation of effective patient safety measures.

Recommendations for Improvement

To enhance patient safety, particularly in lower and middle-income countries, the following recommendations should be considered:

• Foster a Culture of Safety: Healthcare organizations should prioritize creating a culture of safety that encourages open communication, transparency, and accountability. This involves training staff to report incidents without fear of retribution and promoting a non-punitive approach to error reporting.
• Standardize Procedures: Developing and implementing standardized protocols across healthcare facilities can help reduce variability in patient care and minimize the risk of errors. Universal checklists should be adopted to ensure consistency in practices.
• Enhance Training and Education: Continuous training and education in patient safety should be prioritized for all healthcare professionals. This includes regular updates on best practices and simulations to prepare for various scenarios.
• Strengthen Incident Reporting and Investigation: Healthcare systems should establish robust incident reporting and investigation processes to ensure thorough examinations of errors and the implementation of corrective actions.
• Implement Regulatory Frameworks: Governments and regulatory bodies should work to create centralized regulatory frameworks that enforce uniform safety standards across healthcare facilities.
• Utilize Technology: The use of technology, such as electronic health records and decision support systems, can enhance patient safety by improving communication and reducing the likelihood of errors.
• Engage Patients and Families: Involving patients and their families in safety initiatives can empower them to participate actively in their care and help identify potential safety concerns.

Conclusion

Patient safety is a vital concern in healthcare, and the aviation industry offers valuable lessons that can be applied to improve safety practices. By fostering a culture of safety, standardizing procedures, enhancing training, strengthening incident reporting, and establishing regulatory frameworks, healthcare systems can significantly reduce the risk of errors and improve patient outcomes. In lower and middle-income countries, addressing resource constraints and cultural barriers is essential for effectively implementing these recommendations. By learning from the successes of aviation safety, healthcare can progress toward a safer future for patients worldwide. The commitment to patient safety must remain steadfast, with ongoing efforts needed to cultivate an environment where safety is prioritized, allowing patients to receive the highest quality of care. Through collaboration, education, and innovation, the healthcare industry can achieve significant improvements in patient safety, ultimately saving lives and enhancing the quality of care for all patients.

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Dr Lekh Jung Thapa

He is a Senior Consultant Neurologist and Director of the National Neuro Center (NNC) in Kathmandu, Nepal. He is a pioneering figure in the field of neurology. With over a decade long experience, he has been instrumental in advancing neurological care in Nepal, specializing in epilepsy, stroke, and brain tumour management. Dr Thapa is also recognized for his entrepreneurial vision, combining his medical expertise with a commitment to creating a safe, high-quality healthcare system for the Nepalese population. He holds a vision to integrate Safety, Quality, Informatics, and Leadership (SQIL) principles into Nepal’s healthcare system. He is an advocate for combining clinical practice with public health innovation. He plays pivotal role as a healthcare entrepreneur and medical professional, blending clinical excellence with public health innovation, all while maintaining his commitment to community service and national healthcare improvements in Nepal.