Miracle on the Hudson: Lessons for Hospitals

It seems miraculous that US Airways Flight 1549 from New York City landed without loss of life in the Hudson River. The Jewish Talmud says, "Expect miracles, but don't count on them." The airplane designers apparently relied on this in their design of key safety features which enabled a skilled airplane crew to land the plane safely. Seven of their life-saving practices reveal life-saving suggestions for hospitals.

1. Captain Chesley Sullenberger III remembered from his training that if a plane has to ditch, it should be done near a vessel. So he landed the plane near a boat that he saw on that stretch of the Hudson. Other boat captains saw the first boat captain head toward the plane, and they followed, rescuing the passengers promptly.

Lesson for hospitals: Train doctors and nurses on what to do in case of errors as rare as needing to ditch a plane in the water.

2.The plane's first officer, Jeffrey Skiles, was in control of the plane at take-off. But as soon as the plane ran into the flock of birds and both engines quit at about the same time, the more experienced Captain Sullenberger announced, "My aircraft," using the standard phrasing and protocol drilled into airline crews during training. "Your aircraft," Mr. Skiles responded. The airline industry explicitly trains pilots how to manage the change of command of the plane, and the appropriate terse ways to communicate that. This hand-off of authority was clear, immediate, and was automatically documented in the black box recorder. Trainers also teach crew members to routinely "say back" oral orders to ensure they have been correctly understood.

Lessons for hospitals: Create ways to hand off responsibility for patients that are clear, immediate, efficient, reliable, and verified.

3. After Captain Sullenberger took command of the plane, he, First Officer Skiles, and the air traffic controller discussed returning to La Guardia Airport, but decided against it. The pilot didn't decide alone; the three people took time to have a brief discussion, even in the midst of their extremely urgent looming disaster. Airlines have long trained pilots to perform such "crew resource management" (often now called "crisis resource management" in healthcare).

Lesson for hospitals: Train your clinicians to quickly, promptly and routinely discuss critical options for treatment, while driving out subordinates' fear that a higher-ranking surgeon or doctor will punish them for speaking up.

4. A passenger in the exit row was able to correctly remove the emergency exit door because he had taken a minute at that time to "readthelaminatedsafetycardofinstructionsintheseatpocketinfrontofyou." The airline had taken the time to prepare instructions for this very rare event of a water landing and place them where they could be snatched and understood promptly.

Lesson for hospitals: Patients are your partners. Help them by placing a laminated card of instructions in patients' rooms on how and when to call a Rapid Response Team. (It's now a state law in Massachusetts, and perhaps other places, for hospitals to have Rapid Response Teams to reply promptly upon the unexpected sudden deterioration in a patient's condition.)

5. After Captain Sullenberger took command of the plane, he set his co-pilot to work at moving through a three-page checklist of procedures for restarting the plane's engines. Note that the detailed checklist had been developed well in advance precisely for this exceedingly rare event. It was in the cockpit, i.e., it was immediately accessible, and didn't require the co-pilot to have memorized the procedures.

In this case, the checklist wasn't helpful, since it was intended for planes in distress at much higher altitudes, which allows for more time to restart the engines.

Lesson for hospitals: Sometimes you'll get lucky, and the patient will live despite your lack of a checklist. But you should, of course, have checklists for handling the most common errors. Expect laws soon to require the checklists.

6. The plane's force at impact would determine how many would live or die. It was critical to slow the plane. The pilots had to lower the flaps (movable devices on the wing) to slow the plane. But the flaps run on hydraulic power, driven by the now-useless bird-stuffed engines. The Airbus A320 has a "ram air turbine," essentially a little propeller, that drops down into the wind automatically in certain conditions, and produces electricity to provide the energy that allowed the crew to lower the flaps. With this automatic backup at work, the crew was able to slow the plane enough to make what felt like a hard landing, rather than a crash.

Lesson for hospitals: You may have generators that come into automatic use when the electricity fails. Perform a Failure Mode Effects Analysis to identify the failures that are most common and life-threatening, and ascertain where you need other automatic backups.

7. The Army Corps of Engineers is now searching the Hudson River for an engine, which may provide evidence on whether the plane really hit the birds. In effect, the government is helping to determine the cause of the accident.

Lesson for hospitals: Outsiders may be willing to help you find the causes of accidents. Let them partner with you.

Read another story about a pilot.

Thanks to Matthew Wald and Al Baker for the source article in yesterday's NY Times.

A tool for patients and advocates: Hospital error rates

A new publicly available resource shows individual hospitals’ quality ratings, so you can identify the best hospital near you. The U.S. Centers for Medicare and Medicaid Services gathers the information from hospitals across the country and posts it here. The database shows graphs on the treatment of patients with heart conditions and pneumonia, and those undergoing surgery.

Advice: When it’s not raining the roof doesn’t leak, and when it’s raining, it’s too late to go and fix the roof. That’s especially true for personal health issues. That’s why you should take a few minutes now, and pick out the best hospital nearby. That way, in an emergency, you’ll know where to go.

Public Policy Minute: Hopefully, the public availability of quality measures will stimulate hospital leaders to compete on quality. Paul Levy, the head of Beth Israel Deaconess Medical Center in Boston, hopes so, and has posted many measures on a new BIDMC web site. Beth Israel shows up among the top hospitals on all but three of the 21 measures that can be viewed on the CMS database, among its 12 neighboring hospitals. Bravo, Paul!


Not all quality contests are as fair and accurate as CMS’. Read a story of a medical error by a physician who won an award that was not carefully made, or read Paul Levy’s blog post on the public posting of BIDMC’s quality measures.

Advice from a Pilot-Widower - Choosing your surgical team: An anesthesia error

Martin Bromiley is an airplane pilot, the father of two young children. His deceased wife Elaine had long suffered from chronic sinusitis, an inflammation of the nasal passages. Then, early in 2005, one of her eye sockets had become infected. The threat of permanent damage to the optic nerve led her surgeon to recommend a minor operation to straighten the inside of the nose - a possible contributory factor.

Unfortunately, during the operation, she was deprived of oxygen. It appears that moments after being sedated, Elaine's airway collapsed, preventing adequate levels of oxygen from reaching her brain. Though potentially an emergency, the event is a recognised risk during an anaesthetic and, as such, should be manageable. Surgeons and anaesthetists are drilled to follow a series of steps at this point - beginning with a non-invasive attempt to get the patient breathing normally, and ending, as a last resort, with an emergency surgical procedure. This is usually a tracheotomy - where the surgeon cuts through the windpipe, inserting a tube directly into the airway through the throat.

At first the drill was followed impeccably. But then a problem arose: the surgical team tried to get a tube into the airway to help Elaine breathe, but encountered some kind of blockage. According to the drill, this was the time to consider doing a tracheotomy. But the three physicians appear to have made the sort of human error that is horribly common in crisis situations. They became fixated on what they were doing. They also appear to have ignored the junior staff and remained intent on finding a way to insert a tube into the airway. More than a half hour passed before adequate oxygen levels to the brain were restored. Significant brain damage resulted, and she died less than two weeks later, soon after life support was withdrawn.

As a pilot, Martin Bromiley had received the standard training in open communication in the cockpit. Indeed, he is a specialist in this "Human Factors" field. He realizes that "Fixation is a normal reaction to stress. Human Factors training teaches people that it's normal to carry on trying to take the usual action, even when it's clearly not working. But at some point, a decision has to be made to break out of that pattern of behaviour. The way to ensure that happens is for all members of the team to see it as their duty to speak out to keep the patient safe." There was no comfort in knowing that two of the nurses knew how to save his wife's life. "What they didn't know - and what Human Factors [also called in the U.S., Crew Resource Management or Crisis Resource Management] would have taught them - is how to broach the subject with their bosses."


Lesson for Caregivers: Before surgery, verify that the surgical team has been trained so that the surgeon will open-mindedly consider urgent input from nurses and junior doctors. Do this in advance by asking the Risk Manager of the hospital whether the surgical team has been trained in Crisis Resource Management, Crew Resource Management or similar candid team communication techniques. If not, consider scheduling the surgery at a different hospital.


The whole story is told by blogger John Ray, and by Jane Feinmann in the newspaper article "Blunder that Killed my Wife."