Formula One has undergone a safety revolution over the past 30 years, is there similar movement happening in healthcare?
Just a few weeks ago I was following updates from the Patient Safety Congress 2014 on Twitter when I was irritated by a remark reportedly made by Jeremy Hunt. It sounded like he was making a ridiculous comparison, and I’ve heard others express concerns about over stretching comparisons with the airline industry too. There is some value in it by flying a plane is very different to running the NHS. Carl defended the vision and more importantly helped me see that we should be positive about radical change. In part, this is what triggered this blog post:
Carl’s link pointed to the 1955 Les Mans disaster in which 83 spectators and a driver died, and a further 120 were injured when large bits of debris flew into the crowd. Motorsport has come on leaps and bounds: we never see these sorts of disasters and rarely see fatal accidents in the modern sport. Perhaps there is more to this analogy, and perhaps it could be a better comparison than the airline industry too. [Thanks Carl for getting me thinking and helping to spark this post.]
Around the time of this Twitter exchange I had a LoveFilm DVD waiting for me at home, Life on the Limit, which serendipitously turned out to be a documentary about the safety revolution in Formula One. I think I ordered it after being very impressed by TT: Closer to the Edge, Senna, and Rush – all great! I’m not a petrol head, but I am interested in good documentaries and human-machine interaction. On the documentary side I am a bit of an amateur filmmaker, so watching great docs like these is a bit like going to a flash restaurant and appreciating the way the meal has been created, whilst going back home to oven cooking and beans on toast. On the man-machine interaction side I’m a human factors postdoc who looks at the design and usability of medical devices for my research. Both of these come together in Man-Machine Nightmares, which is a film I made about my research few years ago.
Life on the Limit is a great documentary. It tells the story of how Formula One has evolved from a very dangerous sport in the 1960’s to being the much safer sport it is today. It is a story of personalities, advancing technology, competing pressures, tragedy and drive (pardon the pun): this drive is to go faster, to win, and to preserve life.
The result of this journey can be revealed by juxtaposing the first crash the film covers in 1967 where Lorenzo Bandini died in a fiery crash and Martin Brundle’s huge crash in Melbourne in 1996. The first was a tragedy, but it was accepted as part of the risk of this dangerous game.
The second was a triumph for safety (you can watch the first minute or so of the YouTube clip below). After the crash Martin runs down the track to rejoin the race in his spare car! The race was stopped, there are safety barriers, there are plenty of trained stewards, and this crash happened shortly after big changes to improve the safety of the cars. This included raising the shoulders of the driver’s cockpit so if the car flipped that protected the driver’s head.
Over the course of those 30 years there were many deaths, lessons were learnt, and perhaps most importantly there was a culture change – it was no longer acceptable for people to die in the name of sport.
There are a number of messages and comparisons that I’d like to highlight from the film, which I think are pertinent to the human factors and safety movement in healthcare too:
- Motorsport is often focused on the driver, but the safety story is really focused on the system, e.g. the design of the car, helmet, safety barriers, safety car, trained stewards, fire equipment and procedures, protection for spectators, etc. In healthcare we should also focus less on the individual and more on the system, e.g. intuitive medical devices, checklists and procedures, staffing levels, good training, etc.
- For deep-rooted cultural change you need a change in attitude by people who run the business. Racing car drivers will race to the limit – it is up to management to manage and set those limits, so performance is within safe boundaries for everyone. MPs saying safety first is too simplistic when they won’t resource these changes.
- Focusing on why someone crashed or why an error was made is wrong. Instead we should ask why the driver died or why the patient was harmed. Mistakes will always happen and the system needs to compensate for that. Max Mosley pushed for a car that would protect the driver in any circumstances and this is why Martin Brundle rejoined the race rather than becoming the next tragedy. We need a healthcare system that is tolerant to mistakes.
- Similar to motorsport, healthcare has benefited from great technological advances that expand the boundaries of performance. This also adds pressure and complexity to users, e.g. racing drivers take corners at higher speeds, and ICU nurses handle 10+ infusion pumps instead of just one. Safety needs to keep up.
- Public pressure comes from exposing accidents and high profile cases. When tragedies were hidden there wasn’t the pressure for change. It took high profile cases to turn the tide, e.g. by Senna dying. For the first time people wanted to know why this man died and why racing was so dangerous. What are or what will be healthcare’s high profile cases?
- Leaders have a key role to play, e.g. Niki Lauda gave away his championship because he decided that a race was just too dangerous to drive in. This was unheard of. It put safety on the agenda at the highest level. Leaders don’t just go with the flow, they push for the right decision even when this is against the grain.
- We shouldn’t accept the status quo. Many thought the dangers were just part of the game, drivers were expected to put their lives on the line, and not everyone was expected to make it through the season. A few people did not accept this and led the safety movement. They were positive about radical change.
- Being more careful or trying harder aren’t sufficient to bring real advances in safety, it takes something else. Science, investigation, testing, reflection, and improvement have a key role to play. Cars were put through crash tests, and a safety director was appointed who brought wide and far reaching changes to the safety of every race. We need to incorporate the right expertise to achieve this change.
- Lessons learnt from those that have died are not cheap – they should be investigated and improvements made. As Captain Sully, who famously landed his aircraft on the Hudson said, “Everything that we know in aviation, every procedure that we have, every rule in the book, every technique that we have, ultimately is because someone somewhere died… What we have learned are lessons purchased at great cost – many of them literally bought with blood.” Cited in http://www.huffingtonpost.com/brian-goldman-md/doctors-make-mistakes-can_b_1968268.html
- “It’ll never happen to me…” is something that the drivers thought. In a similar way surgeons, doctors, nurses, hospital porters, administrators and directors should not think that it’ll never happen to them, and Trusts should not think that it’ll never happen there. Being mindful means accepting that things could happen. I once asked someone who used to be involved in controlling a nuclear power plant about potential errors, and he said anything could go wrong. I was stunned. I expected him to say nothing could go wrong, and I wondered why someone in charge had this attitude! It took a while, but I realised having this attitude was right for the position, and was one of the reasons why he was in charge.
Going back to the road analogy, towards the end of the film, Max Mosley, who played a key role in some of the changes said that about 3,000 people die on public roads worldwide. Even with an improvement of just 1% we would save 30 people a day, and he hoped some of the advances in safety that had filtered down from Formula One to commercial vehicles had exceeded this. Small increments in safety can save many lives when the scales are massive – so even an improvement of just 1% across all treatment would positively impact a huge number of people in healthcare.
Here we come back to my original tweet, which compared ‘getting the NHS up to aviation safety levels’ to ‘getting public roads up to Formula One safety levels’. No drivers have died behind the wheel of a Formula One car since Senna in 1994, but thousands die everyday on public roads. Can public roads reach the safety levels of Formula One? Probably not. Is the NHS more like a high-class Formula One race that is well resourced, a short discrete race, and highly organised; or is it more like public roads that are messy, are continuously active, and unpredictable? Whatever side of the fence you fall on, and it may be that some parts of healthcare are more like one than the other, we should find solace in the advances that have been made in other domains, e.g. airline and F1; and the small advances that have had huge impacts on a mass scale, e.g. airbags and seat belts. We need to be realistic about the comparisons we make, but we should also be optimistic and present a positive message for change too.
If we are in a safety revolution for the NHS, and someone makes a documentary like ‘Life on the Limit’ for healthcare, who and what would be part of the story? Key parts of the story could potentially be:
- Martin Bromiley’s fight to promote human factors thinking in healthcare and establishing the CHFG which is reported here: http://www.newstatesman.com/2014/05/how-mistakes-can-save-lives#
- Atul Gawande’s Checklist Manifesto which promotes the use of checklists for safer surgery
- Kimberly Hiatt’s suicide after she accidentally gave an overdose to a baby
- The tragic death of Wayne Jowett who received an intravenous drug intrathecally.
- The Mid Staffs hospital scandal where excess deaths and poor treatment were reported.
- The To Err is Human: Building a Safer Health System report which concluded that between 44,000 to 98,000 people die each year as a result of preventable medical errors.
What else would you add? What would the story look like? How does it end?