In January 2004, an Embraer 145 commuter airplane was cleared to land on runway 22 left at JFK airport. Visibility was only about a quarter-mile, just sufficient to fly the instrument approach, and there were thunderstorms in the vicinity and shifting winds. Air traffic control was kept busy routing aircraft around the storms and dealing with runway changes due to the shifting winds. When the runway was in sight, the pilot made a seemingly routine landing. Visibility had improved to about one mile, and on touchdown, the first officer applied the brakes and thrust reversers.
The plane had slowed to about 100 knots ground speed when the captain saw headlights coming straight at the aircraft on the runway. The captain took control of the aircraft and turned off the runway abruptly, avoiding what would otherwise have been a fatal collision with a truck. The controller, who’d apparently forgotten that he’d cleared the Embraer to land on runway 22 left, had also given a maintenance truck the go-ahead to drive down the runway. Had the visibility still been a quarter-mile, a crash would most certainly have ensued. The pilot’s quick thinking and prompt reaction averted a disaster. This is called in the aviation industry a “near miss.”
In March 2006, at The Johns Hopkins Hospital, a patient underwent a gastrectomy for cancer. A nurse came into the patient’s room several days after the operation and was about to inject 40 units of insulin. The patient’s wife, who was ever diligent about her husband’s condition, objected, saying this was far too large a dose. They argued back and forth, but finally, the nurse checked with the physician in charge and came back with a much lower dose of insulin. A potentially serious and perhaps lethal complication was averted by prompt spousal intervention. Another near miss.
Prior to his operation, the patient, despite stringent dietary control, had become diabetic and required fairly large doses of insulin. Several months after his operation, his blood sugars returned to normal and he no longer required insulin. While I was visiting recently with the patient, his wife told me that during the postoperative period while they were in the hospital, he was receiving low doses of insulin—presumably part of our surgical safety program to reduce complications by controlling blood glucose levels. The nurse had mistakenly, for unknown reasons, tried using the dose of insulin that the patient had been taking pre-op.
What is the difference between these two near misses? Simply this: Aviation incidents that aren’t necessarily reportable by law to the FAA are voluntarily reported via an anonymous database kept by NASA, called the Aviation Safety Reporting System. Pilots, controllers, mechanics and other aviation personnel are encouraged to report near-misses, safety concerns and even violations of the FAA rules to this NASA database. Any one of us can access this information. In addition, pilots or controllers who voluntarily report FAA violations cannot be prosecuted based on any information that they provide to the database. It is almost (but not quite) a “get-out-of-jail-free” Monopoly card.
The result is that we know about the runway incursion incident I described above, and all of general and commercial aviation and the government can learn about it and learn from it.
On the other hand, medical errors are buried. I wonder if anyone in the Department of Surgery even knows about the incident I reported above (I should apologize in advance, as I only have the patient’s side of the story to tell here), and certainly I doubt that this situation would be widely and publicly reported.
Hopkins currently has Patient Safety Net, an online system where incidents can be reported anonymously. But those reports stay within the hospital.
What is needed is a publicly accessible patient safety database that encourages anonymous reporting of safety incidents analogous to the Aviation Safety Reporting System that NASA maintains. Shining light on the dark side of health care is the only way to eliminate mistakes.
