A Reputation Built By Success

Politico – ‘Miracle’ Pilot on Mission Against Medical Errors

By: Kyle Cheney, Politico, August 1, 2013

The health care safety world is chock full of airplane crash clichés. Now, a real-life pilot-hero is flying to the rescue.

Capt. Chesley “Sully” Sullenberger in 2009 coolly landed his jet safely on the Hudson River in what was dubbed as the Miracle on the Hudson. He has refashioned himself as an expert on reducing medical errors, which by some estimates kill up to 200,000 people a year – “the equivalent of 20 jetliners crashing per week,” he told POLITICO.

If tens of thousands of people died in plane crashes, he says, “There would be a national ground stop. Fleets would be grounded. Airports would close. There would be a presidential commission. The NTSB would investigate. No one would fly until we had solved the problems.”

But patients die needlessly every day, and it’s barely a blip on the national radar.

Sullenberger has become a fixture on the health care circuit, where comparisons to airline accidents and calls for pilot-like safety checklists have become clichés. He crisscrosses the country, pleading with policymakers to embrace practices to reduce medical errors and save lives. His elevated status as a national hero has earned him top billing at conferences across the nation. Just last week, he was featured at the American Hospital Association’s annual leadership summit in San Diego. He also does some work on aviation and nuclear energy safety, but much of his time since his retirement as a commercial pilot is spent on health.

With a national profile comes national perspective. Aviation safety is nonpartisan. Health care – let’s just say there’s a lot of headwinds.

Sullenberger told POLITICO about attending a private dinner last year with health care industry leaders and members of Congress. After the dinner, Sullenberger approached one lawmaker – he declined to say who or from which party – to ask whether bipartisan consensus would be possible even on something like the next steps in health information technology.

“And [the lawmaker] said, ‘You know, even if we could get the people on the other side of the aisle to agree to this, I would question their motives. I would think they had some ulterior agenda,'” Sullenberger recalled, to which he replied, “‘I don’t mean to be impertinent, but if we could achieve these … would their motivations really matter to you?’

“And he looked at me as if he never even considered that possibility and said, ‘No, I guess not.'”

Sullenberger says his push to end “balkanized” health care delivery in favor of more coordinated and safer care was a natural transition from his 30-year career in aviation. They are both complex systems with intrinsic risks. Mistakes can be caused by individuals, by bad communications, by defective equipment – and through faulty systems.

But the aviation industry and the relevant government agencies have minimized death by human error. But deaths from medical errors are still strikingly common. It’s not just “bad apple” physicians. The systems are at fault, too.

The pace of change frustrates him.

“My message is we should be less patient,” Sullenberger said. “We should reject the status quo now, not 20 years from now, because it’s failing us. I’m not happy with what’s happening. The rate of change, the rate of improvement in patient safety has plateaued.”

Many of the solutions, he added, are “not dependent on political will.” He suggests raising public awareness, delivering reliable data on medical errors and relating that data with “compelling personal storytelling” will do a lot to address the problem. Sullenberger also advocates for the use of checklists by health care providers – a recommendation advanced by physician-author Atul Gawande. He also wants a whole different approach to reviewing medical errors, figuring out what’s behind them, not just blaming doctors and nurses.

“In every unit in every hospital, there inevitably are going to be particularly tragic, preventable deaths. They all know their names … just as pilots in our generation can cite chapter and verse all the seminal accidents and aviation history,” he said.

That knowledge, Sullenberger said, lends itself urgency – the kind of urgency he says isn’t on display today.

“It’s not enough. There are still lives being lost needlessly. And it is frustrating,” he said.