Thursday, May 6, 2010

Captain "Sully" Sullenberger: Safety Messages from the "Miracle on the Hudson"

I was excited to listen to a safety presentation recently by Chesley B. "Sully" Sullenberger III. The room of about 400 healthcare personnel from the Kettering Health Network (KHN)was silenced as Captain Sullenberger showed a National Transportation and Safety Board (NTSB) recreation of the flight path, instrument readings (altitude and airspeed), and actual pilot and air traffic controller voices concluding with the dramatic landing on the icy cold Hudson River (captured on film). As a former Army helicopter pilot and instructor pilot, I could feel myself becoming tense as I listened to the rapid communication from tower to pilots and even tenser as the altimeter neared two hundred feet with the airspeed at 130 knots (more than 130 miles per hour).

The pilots no longer responded to the tower that just before impact suggested yet another alternative landing strip- eleven minutes away! Truly,they were on their own with no engines in a heavy object being pulled to the earth's surface by the force of gravity. The view on the screen suddenly changed to live video of the plane showing up on the right, about thirty feet above the water and splashing down like a huge sled, sliding rapidly along in a continuous spray of its own making. It disappeared out of camera view and the room of viewers felt a sense of relief. Even though I'd seen the splashdown a hundred or more times on TV, I still felt uneasy about the outcome until our speaker calmly reported how they felt as the passengers and crew were helped off the plane onto the wings and suddenly converted passenger ferry boats in a busy section of the Hudson River. They survived again!

The emergency landing riveted us to the concept of safety, Captain Sully then shifted to 200,000 medical deaths yearly, noting that many may have been premature due to errors. In aviation there used to be a death rate of 1 person per one million hours of flight, now it's 1 person per 10 million hours of flight. The improvement comes from safety improvements. So what are we to do in medicine? Get safer! How do we get safer? Use checklists and practice our routines. Sully pointed out how the use of operating room checklists at a Pittsburgh hospital dropped their peri-operative infection rate to zero.

He pointed out that the use of checklists promotes teamwork, leadership and followership. It also generates the flexibility to face the unexpected, he stated as he referred back to "The Miracle on the Hudson", giving details as to how the use of checklists and crew practice enabled two pilots who just met three days earlier to pull off an incredible landing. He repeatedly emphasized that the entire crew of their flight had performed admirably and succeeded because of a deep understanding of the routines they had practiced.

So, I'm thinking of my days as a rotary wing aviator (the Army term) and using checklists for starting and preparing for takeoff and landing. I used a checklist for every flight in Vietnam and flying out of Ft Riley, Kansas. I remember how shocked I was to find in medical school in the 1970's (at The Ohio State University College of Medicine) that doctors did not use checklists. I thought that engaging a human body was much more complex than a helicopter, especially since the body also had a person inside. And so, we memorized and practiced, making sure that the patient never saw us refer to any checklists that would harm the interaction.

I flashed back to the head of surgery at OSU who had left a gauze sponge inside Woody Hayes, the famous football coach for the Buckeyes, and made the front page of The Columbus Dispatch. I remembered an angry, cursing, verbally abusive plastic surgeon at OSU berating the operating room nurse repeatedly, rising to threatening intensity as the sponge count (even without a visible checklist, every surgeon called for the sponge count before closing up the surgical incision) came up short one sponge. He vehemently insisted that all the gauze sponges were out of the patients massive facial cavity where a huge malignant tumor had been present. He was wrong and found the bloody gauze stuffed into a corner of the winding wound. She confronted his behavior and stated her intention to report it to her and his superiors. He was known for intensity and verbal abuse in the OR. I was very pleased that the nurse had confronted him (after he had closed the now spongeless wound) and reported his behavior. Could a checklist make a difference in situations such as these?

As Sully noted in his talk, behavior that detracts from the team is bad for quality outcomes and bad for the bottom line of the institution. He also pointed out that practice with a checklist enables the team to better understand each other and to clarify roles, enhancing or establishing mutual respect. I know that he was primarily referring to hospital safety, but I began to reflect on family medicine offices. My office team could benefit from a few procedural checklists for training and a daily team meeting with a checklist to get the patient care day started. Thanks Captain Sully for an excellent motivational talk to enhance our potential to improve quality and patient safety!


  1. Wow great analogy! Routine is greatly enhanced by practice and a checklist creates uniformity and reliability.

  2. I spoke with an FP leader at Geisinger yesterday. He told me that their system now guarantees a positive outcome from certain kinds of surgery for up to 180 days after the surgery. that means if the patient needs to be re-admitted for a complication associated with the surgery there is no charge for the service. Geisinger is now receiving patients from many sources because the insurers value this promise and this performance. Amazing.

    And what is the single most critical thing outside of the surgery itself that accounts for this outcome? If the patient receives a post surgical antibiotic within 60 minutes of the closing, they have zero infection. He said it took them a great deal of work (and checklists) to get this seemingly simple action performed routinely.