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Comment by calinet6 | Hacker News Reader

The problems are not inept individuals, nor will scaring people out of the field improve conditions.

More than likely, the fear of recourse causes more error and malpractice than the errors themselves.

Think for a moment: why are commercial airplanes so safe? Why when an airplane crashes is it so rarely "pilot error?" And why, when it really is pilot error, does the pilot not get blamed? It is because of profound realizations in the design of the air travel system that veered toward systemic control of air traffic and its safety, rather than individual pilot accountability.

I will say unequivocally and factually: our health care would be orders of magnitude safer and higher quality if we treated it in exactly the same way.

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In my experience, in an unrelated field, most human errors are actually a cumulation of other systematic errors.

Pilots are responsible for safety, sure, but there are multiple checks in case the pilot suddenly passes out (or stops paying attention, or whatever). Control towers, copilots, etc.

I know nothing of anesthesiology, but it seems to me that a doctor shouldn't be a single point-of-failure. If he is, it seems like that should fall under systematic-errors.

What a great point. Raver kids have quick and easy litmus tests they can use to make sure the illegal drugs they're taking are the ones they expect to be taking. If it turns blue, you take it. If it doesn't, you don't.

It seems the procedure for injecting medicine into your spine should have at least as much fail-safety built in.

In cases of wrong medication, I wonder if its a mislabeling or someone just not reading? Maybe a doctor writing the wrong thing down?

You are missing the forest by looking at the trees. You need a foolproof way to determine 2 tests:

1. Is the contents of the bottle what I think (or the label says, or the nurse told me) it is?

2. Is the verified contest of the bottle what we previously agreed this patient needs?

1a. Is the concentration of the solution is this bottle as high or as low as I think?

Read "The Checklist Manifesto" by Atul Gawande. Chock full of tiny, easy steps like this that make huge differences in outcomes.

In medicine, one big thing is people working long hours, exhausted. My understanding is that airline personnel have strict rules about this. I have long thought medicine should seriously tighten up on making sure medical personnel are adequately well rested instead of insisting that residents work 36 hours straight and things like that.

We allow doctors to cut into other people in the same circumstances in which we (at least in EU) forbid a truck driver to drive because he's a danger to others because of insufficient rest.

Worst case scenario for the surgeon is a single death, worst case scenario for the truck driver is dozens. Better stay out of hospitals...

There is a tradeoff, though. A doctor once explained to me that she did 24 hour shifts to minimize the mistakes that can occur when handing a complicated case off to someone else.

I think that sort of thing accounts for an extremely tiny minority of too-long shifts in the medical industry.

Medicine would do well to learn from aviation.

Aviation safety is all about treating errors as facts of life, and erecting as many barriers as possible between errors and a catastrophic outcome. When errors do happen, everything is designed to trap them as early as possible before they cascade into something worse.

There are compelling incentives (such as amnesty or leniency) for pilots to self-report the mistakes they make. The entire industry has robust safety reporting mechanisms, and virtually every non-trivial error is dissected in reports for later study. When there's fatalities involved, you're talking a full NTSB investigation.

Google also has a robust `post mortem' culture. (Transporting the term back to medicine where it came from might be a bit morbid, if used in the newly acquired wider meaning of any analysis of failure after the fact.)

In the Army (90s), we called them "after-action reviews" (AARs), for the avoidance of highlighting morbid parallels.

For pilots, its called the NASA Aviation Safety Reporting System [0], which does have immunity (from FAA enforcement actions) for self-reporting pilot mistakes.

The NTSB often "full" investigations into serious incidents involving airliners, such as runway incursions or other near-misses.

In the USAF there is a legal Accident Investigation Board, and a Safety Investigation Board. The SIB is legally privileged, and testimony cannot be used in disciplinary action or legal proceedings.

For doctors, there is whats known as a Morbidity and Mortality conference [1]. This is a meeting between doctors at a hospital in which the discussions are privileged and confidential.

[0] https://en.wikipedia.org/wiki/Aviation_Safety_Reporting_Syst...

[1] https://en.wikipedia.org/wiki/Morbidity_and_mortality_confer...

> Treating errors as facts of life.

Even the passengers are part of the system. Example: those cigarette ashtrays in the bathrooms? They're not left over from some mid-century period where you could smoke on planes—they're very intentional and there to prevent fires in the event someone does smoke on a plane, which, since it's a very plausible and easy to make human error, must be accounted for safely and systemically.

That way of thinking permeates air safety thinking, and it's why air travel is safe, period.

I strongly disagree - it sometimes is inept individuals in the medical field who cause mishaps, I watched a young clearly inexperienced anesthesiologist attempt to perform a spinal on my wife during labor - he spent an entire hour attempting to insert the needle between the blades of my wife's spinal column before calling for help. Rather than admitting he had either:

a) never done the procedure or b) was unskilled in its application

he attempted to perform it himself, and for reasons unknown thank god he didn't insert the needle into the spine incorrectly. The experienced anesthesiologist took a minute or so to do the same procedure.

So yes, even in the medical field there are inept individuals who think too highly of themselves to admit & seek help when they're clearly incapable of performing the task at hand. Unfortunately those weaknesses cannot always be detected (i.e. diagnosis, etc.) without second opinions - but hey, that's why there's malpractice insurance...

Plane crashes caused by pilots and doctors with medical malpractice incidents cannot be compared. In the event an airline pilot causes a plane to crash - the pilot is committed to the outcome, he's in the plane. There's no equivalent in the medical field - inject the wrong drug in a patient and its a learning experience with possible negative side effects for the patient.

You can ask why that anesthesiologist didn't ask for help. Or you can ask why a clearly inexperienced anesthesiologist was assigned to perform a dangerous procedure with no supervision.

He was afraid of punishment for not knowing how to do his job.

Remove the punishment, create a systemic environment of improvement rather than individual blame, and he can easily speak up and say he's not prepared for the procedure and get help.

Without that, he's afraid of being fired or discovered as "inept," none of which will help him become less inept, which is the only goal that matters.

The question is not how we weed out inept doctors, but rather how we create a system that improves doctors systemically so that as few as possible are unqualified for as little time as possible. Thinking about this as an individual problem is unhelpful and inconsequential to any real change.

Actually, despite air travel being so safe, the primary cause of fatal airplane crashes is pilot error[1]. And I see no proof in those instances that the pilot isn't being blamed.

1.http://www.planecrashinfo.com/cause.htm

EDITED to add "fatal."

The pilot is deemed at fault, but he usually isn't fired or heavily fined for the accident unless it was a flagrant violation (like he was trying to join the 410 club and core locked the engines). The passengers don't sue the pilots.

Well, I was referring primarily (and in the referenced link) to fatal accidents. Usually it's a bit harsh to punish one of the most likely fatalities.

> Well, I was referring primarily (and in the referenced link) to fatal accidents. Usually it's a bit harsh to punish one of the most likely fatalities.

Aside from being harsh, its usually also, you know, impossible.

> but he usually isn't fired or heavily fined for the accident unless it was a flagrant violation

> passengers don't sue the pilots.

Well, a lot of the times they're all dead.

In fact, passengers are "all dead" in far fewer plane accidents than people tend to think (even if there are fatalities or injuries).

However, it looks like families are more eager to sue than actual victims...

Just because the pilot is identified as the cause does not mean that anyone is blaming the pilot for being negligent. If a pilot sneezed while landing he's still the cause but that certainly doesn't make him negligent just because he made a mistake. Aviation (and computer science for that matter) is built around mitigating faults and mistakes at every level, that's the biggest part of why air travel is so safe is that it's designed around failure being acceptable. There are contingencies for anything that can foreseeably go wrong because in reality nothing is perfect, and certainly not the pilots.

We need to be treating doctors how we treat pilots.

I think that the acceptance of failure in certain domains is a problem of system design. Why shouldn't doctor, pilots, ship's captains, train conductors etc be held accountable (blamed) for mistakes? I don't agree with your statement that air travel is designed around the acceptance of failure meaning that pilots aren't culpable for their mistakes. Watch a NTSB hearing into a pilots failures, and there's plenty of blame assigned when appropriate. Doctors and other medical professionals should be similarly scrutinized and ostracized when they perform poorly.

> And why, when it really is pilot error, does the pilot not get blamed?

Because he's dead? The airlines (the hospitals) do get blamed: http://www.usatoday.com/story/news/nation/2013/07/08/asiana-....

It's actually much easier to blame a dead pilot. Dead men mount no legal defenses.

Yes, but dying is basically the stiffest penalty for errors you can think of.

It certainly simplifies things, which is why perhaps the air travel question is so much easier to make a conclusion on.

"Well, if a pilot makes a mistake, we can't exactly punish him after the fact in most cases... so our normal primitive blame systems won't work here. Hmm, what can we do instead?"

And by George, we stumbled upon an actual way to improve the whole damn thing. Perhaps only by a trick of psychology that we couldn't apply blame and fool ourselves into thinking it was working.

Its relatively rare for a pilot to crash an airliner and be formally cleared by the NTSB. My understanding is that Capt. Chesley "Sully" Sullenberger was formally cleared by the NTSB after US Airway 1549, as there was no way that Capt. Sully could have avoided the birds, or returned to LaGuardia, when following appropriate procedures.

Its more common that the NTSB rule that "human factors" was one of the factors in an accident. This would include what is (often incorrectly) called "pilot error".

Pilots are often fired when they screw up and wreck the aircraft. The Captain of the Southwest 737 that crashed landed at LaGuardia was fired.

You can't go too far off the deep end and never place blame, but I think it's safe to say that the air travel system has considerable incentives for acting in favor of the system's improvement vs. in favor of individual blame/responsibility, and that's made it what it is today.

"Human factors" is another way of saying "this is something in the system that's error-prone that we haven't controlled yet, but maybe we should if the statistics say so."

> why are commercial airplanes so safe?

Because the planes fly themselves. The pilots are only there for the occasional emergency (where they often screw up because they're not used to actually having to fly the plane).

And in reality, the operation of an aircraft is not the principle point of failure. Rather, mechanical failures, weather, sabotage, etc. are much more easily eliminated by rigorous inspection and heuristics with multiple failure points.

The fact that commercial pilots (with numerous hours of experience, strict certification and simulator requirements and often, military backgrounds) are considered a principle risk point is only because the safety standards of all the other modes of failure have been so robustly reduced.

Exactly. If pilots (humans) cause errors, the safest system removes them from the equation as much as possible, except in the parts of the process where it would be more error-prone not to.

Point re: screwing up because the plane is normally flown for you; yes, but that's still safer overall without a doubt than optimizing for pilots doing much of the flying manually much of the time. Occasional emergencies are far better than predictable human error all the time.

I would imagine it's partly an emotional thing; it's hard to blame the pilot or think that the pilot was negligent, when clearly any error he makes can be fatal to him as well as the passengers.

Whereas if a doctor makes a mistake, nothing really happens to him. Thus it's easier to imagine he's just being negligent / doesn't care, which generates more anger than an honest mistake.

Forgetting blame, why don't pilots screw up as often?

How many pilots are in a cockpit?

How many anesthesiologists are in a surgery room?

There's your problem.

How costly is it to train a pilot? How costly is it to train an anesthesiologist? How costly is it to hire a pilot? How costly is it to hire an anesthesiologist?

How many customers can an anesthesiology team service per day? How many customers can a pilot team service per day?

Is this from Charles Duhig's or Gerd Gigerenzer's book? I remember reading somewhere this exact thing.

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