The Most Important Patient Safety Action to Take in 2014 According to LifeWings

Share Article

Manage your culture or it will manage you. The ongoing investigation into the Asiana crash this past summer in San Francisco has reinforced that the number one safety, quality, and cost issue affecting healthcare today -- the unwillingness of staff to hold one another accountable and speak up when they perceive a problem with patient care.

The ongoing investigation into the Asiana crash in San Francisco on July 6, 2013 has reinforced the number one safety, quality, and cost issue affecting healthcare today--the unwillingness of staff to hold one another accountable and speak up when they perceive a problem with patient care. This is a problem Steve Harden, CEO of LifeWings addressed recently in his January 2014 newsletter.

Captain Harden wrote about the Asiana crash in his earlier August newsletter. He said then, "that the Korean culture of saving face, and deference to authority would turn out to be a key factor in the cause of the accident."

An Associated Press article by Stephen Braun and Martha Mendoza, December 10, 2013, detailed the Asiana flight crash including the Federal accident investigators interviews with the pilot of the B-777 jet that crash-landed at the airport last summer. Though Captain Lee was an experienced pilot with the Korea-based airline, he was a trainee captain in the 777, with less than 45 hours in the jet. Captain Lee's co-pilot on that fatal flight was an experienced instructor pilot who was responsible to mentor and monitor Captain Lee's performance.

The AP article also says the 46 year-old pilot told investigators he had been "very concerned" about attempting a visual approach without the instrument landing aids, which were turned off. In the same article Lee also said, " the fact that he would be doing a visual approach in a jet as big as a 777 particularly troubled him. But, he did not speak up because other airplanes had been safely landing at San Francisco under the same conditions." As a result, he told investigators, "(he) could not say to his instructor pilot (that) he could not do the visual approach."

The actual interview summary written by the National Transportation Safety Board is available here. Throughout the transcript of interviews with Captain Lee, Harden says, " the responses to their questions, and how they reveal the effect of the Asiana culture on safety issues, are absolutely chilling." Harden adds, " this reveals that even though he is the captain of a modern jetliner responsible for the lives of 200 passengers, in the Korean culture he must defer, at all times, to the instructor pilot."

Captain Harden emphatically stated, " after working with over 140 healthcare organizations, reviewing scores of root cause analyses, and conducting hundreds of real time observations in hospitals, clinics, ASCs, and labs - many of my experiences with healthcare staff sound just like Captain Lee's interview. The culture in many healthcare organizations might as well have been created at Asiana."

According to Captain Harden, "the number-one thing you can do for patient safety in 2014 is confront this culture." He says to ask yourself, "In 100 out of 100 cases where it is needed, am I absolutely sure that my most junior and inexperienced staff member, when they perceive a problem with patient care, can and will have a stop-the-line conversation with my most senior and experienced physician? If you cannot answer that question with an emphatic "YES!" and do not have a formal, systematic, proven plan in place to change your culture so that you can answer "yes", you are missing the boat in 2014."

Newsletters addressing how to change the culture of an organization using LifeWings principles:

Four Ridiculously Simple Steps to Ensure Sustainable Improvements
Why Your Staff Doesn't Take You Seriously About Speaking Up for Patient Safety
50% of Your Staff Won't Speak Up for Patient Safety: Six Things You Must Do About This
Three Things You Must Do Before You Start Your Change Initiative Action

For more information on LifeWings:
Like us on FB:
Follow LifeWings on Twitter: @LifeWingsLLC

Share article on social media or email:

View article via:

Pdf Print

Contact Author

Stephen Harden
Lifewings Partners, LLC
+1 (901) 457-7505
Email >

Angela Myers
LifeWings Partners, LLC
Email >
Visit website