In some quarters, checklists have resulted in dramatic reductions in infections, such as reduction of central line bloodstream infections at some hospitals down to zero. “But how can it be sustained. Aviation has done it, but medicine has not. Why?”
He alluded to a variety of problems.
“Conventional wisdom often has it that if a nurse makes a mistake, he or she should be terminated, but the vast majority of harmful events are due to system failures not practitioner error. The leaders are responsible for the maintenance of these support systems, not the caregivers. And the current punitive culture only drives problems underground where they can never be examined or solved.”
“Burying errors for fear of shame or retribution only sets a trip wire for the next practitioner who comes along. Blaming only individuals when there are systemic deficiencies not only doesn’t solve the problem. It doesn’t prevent it from happening again.”
Additionally, he said, providers have not done a good job quantifying the cost their errors. In fact, he said, research shows that those same 48,000 deaths cost hospitals $8.1 billion, which they may well have saved.
“In every organization we must know what our infection rates are and right now, that’s just not the case,” Sullenberger told the hospital officials. “Federal legislation is about to link health care payments to the quality of service. I believe in 10 years, when this is integrated throughout the system, we’ll look back at where we are today and will know that we were flying blind.” The audience gave him a standing ovation.