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 Being a professional in the business of healthcare, regardless of specialty, means working at "The Sharp End" of a complex human system. It's a place where the penalty for failure is very great in both human and monetary terms - a place in which human mistakes can easily metastasize into significant accidents grossly affecting or even ending lives.

  While the medical profession seems all the lonelier for this high-wire act characteristic, it does not have an exclusive franchise on life at the sharp end. Other businesses and professions exist which also face a continuous human and monetary penalty for any significant failure or incapacity, among them the nuclear power industry, and perhaps most widespread, aviation.

  Especially aviation!

  The users of the aviation system accord the practitioners (pilots, flight attendants, airline managers) the same level of blind trust most patients give to their health care providers. And, like medicine, aviation as a system is extremely vulnerable to human mistakes. In fact, more than 90% of all aviation accidents result not from mechanical failures, but from human failures - human failures usually nurtured, created, or caused by the system in which the flawed humans were working. That realization has created a crisis, and a revolution in aviation safety in the past fifteen years, and led to profound changes.

  Medicine, too, is facing a crisis, and a need for a revolution. While Risk Management awareness has burgeoned throughout the healthcare industry in the last few years, the practice of managing risks has too often simply reinforced the medical "Blame Culture," the tendency to ask only one question in any incident, accident, or problem: "Who's wrong?" rather than the systemic question, "What's wrong?" The flawed, inherent assumption of the "Blame Culture" is that human error is largely volitional, and that the "system" is only culpable if it has failed to eliminate such flawed humans before they erred.

  The reality is quite different.

  Aviation has been down the same road, and it turned out to be a dead end. In fact, until the mid-eighties, hundreds of passengers were dying needlessly every year because airlines, military aviation programs, and even private aviation had great trouble understanding that professionals do not fail because they want to, they fail for two reasons: 1) Humans are forever imperfect; and 2) Systems which are NOT constructed to safely absorb anticipatory human mistakes are doomed to foster expensive and disastrous accidents caused by those mistakes.

  And what human incapacities are we talking about? For starters, fatigue, distraction, attitude, anger, upset, personal emotional trauma, task saturation, confusion, misunderstanding verbal input, and many other well known, well understood human frailties - including the inherent failures to communicate which frustrate teamwork and fragment large organizations.

  What this presentation is all about, then, is changing an entire culture: breaking down the barriers that block communication among professionals, getting rid of the blame culture, and instilling true teamwork in every corner of the organization. Aviation has killed a host of innocent people in learning these lessons. In fact, you could say we've paid in blood for them. You will hear some galvanizing aviation stories in this presentation, stories set in cockpits instead of operating rooms or ICU's. But the world you'll enter is so similar to healthcare in terms of the human dynamics that the lessons can be lifted intact from that world to yours.

John J. Nance