Texas Tech University Health Sciences Center
Into the Raging Sea

Into the Raging Sea

Each day in thousands of hospitals and clinics all across America, medical decisions are made and medical procedures performed. All of these decisions and procedures have consequences. In the vast majority of them — the consequences are beneficial to the patient and yield the intended results.  The decision is spot-on and the outcome of the procedure goes perfectly well. But, sometimes decisions are made or procedures performed that have unintended, undesired and, yes, even fatal consequences.

According to a 2016 Johns Hopkins Medicine study, medical errors are the third leading cause of death in the United States behind cancer and heart disease. The Centers for Disease Control and Prevention reports one-in-25 patients will contract at least one hospital acquired infection during their stay.

How do we minimize adverse occurrences? While we realize people and systems are not perfect — nor will they ever be – we can (and must) strive to mitigate mistakes, especially if patient harm can be prevented.

One way to do this is to be a high reliability organization. By way of definition, such an organization is one that operates in complex, high-hazard domains for extended periods without serious accidents or major failures. Health care, aviation, nuclear power generation plants and maritime activities — all fit into this category. In a high-reliability setting, the results of mistakes are too great to allow, such as a nuclear meltdown, a crashed plane, a sunken ship or harm to a patient.

I recently read a book, “Into the Raging Sea,” a fascinating true story of disaster and death at sea. These days, fortunately, it is rare for a large ship operated by a major operator to sink.  But, it happened, three years ago, October 1, 2015. Hurricane Joaquin wiped out El Faro, a container ship sailing from Jacksonville, Florida, on its regular route to San Juan, Puerto Rico. The ship carried containers (like you see on railroad cars) and vehicles. The 33 people on board El Faro all died.  The National Transportation Safety Board conducted an investigation, eventually recovering the “black box.”

These are the lessons I gleaned from the book that have applicability to health care:

  • Practice persistent mindfulness.  Safety really is job one. We cannot take our eyes off safety and safe practices for even a minute.  
  • Overcome communication barriers due to hierarchy. In the case of El Faro, many of the officers and crew knew they were headed directly in the path of the hurricane but were reticent about speaking up. Why? Maritime tradition and protocol. Our “Speak Up!” campaign is a great idea.
  • Gather the latest facts and the best information available. In this disaster at sea, the captain seemed to rely on weather reports that were not timely and out of synch with comparative reports.
  • Seek cost-saving opportunities, but not at the expense of safety.  In this case, (it appears) the captain refused to divert from the path of the hurricane because it would be too expensive in terms of fuel consumption to take an alternative route. 

Texas Tech Physicians’ mission is to be “top-tier” and that involves quality patient care . Patient care includes safety, an essential and non-negotiable part of quality.  Have a great week!