Lessons learned by Surgeons and Pilots

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Geez, Mike, you've always been MY hero - I just never knew that I had to share you with that many people!!!

Ron


-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Sise, Mike MD
Sent: Saturday, May 09, 2009 11:53 AM
To: trauma-list at trauma.org
Subject: Lessons learned by Surgeons and Pilots

Lots of twittering about pilots;

My brother flies 757s for one of the big airlines. The more we share war stories the more I see the similarities in our errors. I now do all of my vascular surgery with a checklist of my own creation. We hang them on an IV pole at the head of the OR table for all to see. I've attached examples (notice the last step). The residents love them as teaching outlines. A quick audit revealed that we would miss a step - the vast majority minor - in 20% of cases without the list. I've done over 1,000 of each of the cases I use the lists on. In trauma cases, it's not as easy to generate a useful checklist - but we're working on it.

We looked at 10 years' worth of our TQI minutes (Trauma M&M) at our Level I trauma center and found that most of the preventable deaths and major harm events were due to provider error (almost all attending trauma surgeons). Everyone of these provider errors was due to one or more of three factors: 1. familiarity or senior experience 2. distraction 3. fatigue.  My pilot brother tells me that those are the three dominant errors in pilot performance that lead to major crashes.

I'm at a point in my career where I'm ready to learn from any group that has something to teach me about human error and improving performance.

Mike Sise
San Diego

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