One way to handle a near miss

The Blue Angels, the Navy's elite aerobatic team, have cancelled their annual performance at the Naval Academy's Commissioning Week. Why? Well, they had a near miss during a recent show:

"There was a deviation from the standard flight parameters during the show,” Kelly said.

The performance was halted and the Navy decided the team needed to head back to Pensacola for training and practice.

Let's think about the difference between this and the usual practice in hospitals. A near miss occurs. Most times, no one notices. Many times, no one says a word, even if the event is noticed. Some times, someone says something, and nothing happens. Still fewer times, someone says somethings and reports it up the chain of command, and nothing happens. Fewer times still, after it is reported up the chain of command, a root cause analysis is done. Fewer times still, after the root cause analysis is done, a change in protocol is designed and tested, and, if effective, training is carried out and implementation of the new protocol spreads through the organization.

For every reported adverse event in a hospital there are at least an order of magnitude, and perhaps two or three orders of magnitude, more unreported events. For every unreported event, there is a similar order of magnitude difference in the number of near misses.

Imagine if we had a standard of care in hospitals equal to that of the Blue Angels.

Nah, it can't be worth it. After all, they have six people to worry about, so many more than go to hospitals.

And the consequences of errors in hospitals are so insignificant.

Nah, it can't be worth it. After all, these things happen.