How Leaders Can Get an Eightfold Increase in Patient Safety
Updated: Jul 20, 2021
We used to hear the flight attendant command passengers to turn off their cell phones once the cabin door was closed and the airplane is ready for pushback. They were very serious about it... “Everything with an On/Off switch must be powered down now,” the stern voice intoned over the loudspeaker. If you don’t comply, you just might get arrested, just like the actor Alec Baldwin because he refused to quit playing “Words with Friends” on his iPhone - despite repeated requests from the flight attendant.
Back then, airline officials wanted us to think that your cell phones and computers will interfere with the airplane’s complex and sensitive electronics, leaving you with the impression that if you leave your cell phone on, the airplane will surely crash.
Having been a professional pilot for 42 years, flying all sorts of complex, computer-driven airliners, I can assure you that your cell phone does not, and never did, interfere with anything on the airplane. The airplane is in no danger from your cell phone, but you might be.
The real reason the airlines wanted you to turn off your electronic equipment is because of the potential distraction to you during the most dangerous parts of the flight. It is a well-known fact in commercial aviation that the phases of flight most likely to have an accident are during taxi, takeoff, and climb to 10,000 feet of altitude, and then during descent out of 10,000’ to approach and landing.
Respecting the increased odds of a mishap, the airline wanted you to shut off your electronic devices prior to push back so that you will not be distracted from responding to the flight attendant’s safety commands should an emergency evacuation be required on a taxiway or runway. If you need to get out of a burning airplane fast, they didn't want you texting, calling, or checking CNN to see if your airplane emergency is “Breaking News.” As we all well know, the distraction of texting while driving kills. Texting while evacuating a stricken airliner can kill too.
By the way, it is a Federal Air Regulation (federal law) that pilots are prevented from chatting or doing paperwork during those phases of flights as well. It’s called a “sterile cockpit” and during those times the only communication or activity that is allowed must be directly related to the operation of the airplane.
Pilots taxiing to the runway for takeoff who are caught by the FAA chatting about what they had for dinner last night can easily lose their pilot’s license. Distraction kills.
So what does this have to do with patient safety?
Distracted clinicians can cause patient harm and death.
A recent study conducted in the surgical services revealed that these fairly simple distractions...
Unexpected movement by an observer;
A cell phone ringing and answered by an observer;
An unrelated conversation between an observer and a third party;
The noise made by dropping a metal tray;
A question about a problem that came up regarding a recovering patient; and
A question about a resident’s career choice
... caused an eight-fold increase in major medical mistakes during surgical procedures.
Additionally, more than 50% of the physicians in the study forgot a key surgical task when these distractions were present. In comparison, only 22% forgot a memory task when there were no distractions.
Read the list of distractions again.
These are common, and happen every day in every facility. And they can be deadly.
This is why effective leaders adopt a term like “Delta.” Anyone on the team can call it out and invoke the protocol of “sterile cockpit.” Code words like “Delta” mean the undivided attention of all clinicians involved in the care of the patient is needed immediately. All social conversation should cease, the music should be turned off, and unnecessary, non-operational movement, paperwork, or activity should stop.
Everyone should focus on the patient and the task at hand. (There is nothing magic about the word “Delta,” you could choose any code word. The important thing is to have a word.)
Distraction control is also why effective leaders create a quiet zone to prevent distraction when nurses enter medication orders. Quiet Zones need to be little more than a computer terminal in a corner of the room behind a neon orange sign on the floor that reads “Shh ... We’re in the MedZone.”
These protocols have been shown to cut medication errors by two-thirds, saving money and lives. These safety tools are decidedly low-tech and low-cost. Employ the term “Delta” and create a quiet place where nurses can place medication orders without being interrupted.
Result? Get a dramatic increase in patient safety.