How did the airline industry reduce errors and improve safety? During 1967-1977 the risk of dying from an airplane crash was 1 per 2 million flights. Following pressure from within and without, the airline industry developed safety standards reducing that risk to 1 per 8 million flights by the 1990s as reported in “To Err is Human” 2001. This change was achieved through the following means:
A) Establishing and setting standards
B) Maintaining multiple databases to monitor trends
C) Supporting research to improve systems
D) Developing non-punitive reporting system
By defining the time allowed a pilot to fly before a rest break occurs; implementing emergency procedures, establishing safety systems, centralizing data collection, monitoring trends, and mandating certain criteria, the airline industry improved its safety track record.
How did the automobile industry reduce errors? The automobile industry has used Total Quality Management (TQM) format to decrease errors, thereby increasing efficiency and profitability. The Japanese automobile and electronic industry rose to efficiency through quality management programs like TQM. The emphasis with TQM is on increasing efficiency, improving quality of goods, and decreasing errors by making everyone along the process share responsibility for the end result. The standard to always improve from previous numbers requires constant adherence and attention to processes and routines, so that the numbers reflect constant improvement through continuous processes. There is nothing static about this program application.
After the US saw the benefits of the Japanese industrial methods, implementation of TQM began in earnest within the US manufacturing industry.[7]
W. Edwards Demning, a mathematician in the early 20th century, put forth the theory that production errors occurred 85% of the time from system failures, and only 15% from worker/individual responsibility.[8] Yet, historically, the worker is admonished and required to change, instead of changing the system through revisions or corrective process measures. In reality the failure is often in the system, not just with the individual.
How can systems work to reduce errors?
By simplifying processes, improving communication,
increasing management support, decreasing punitive
punishment environments, instituting practice guidelines,
pathways, and policies to support error reduction.
What about the space program?
What does the Challenger accident have in common with healthcare?
When the Challenger accident occurred, the initial reaction was for the manufacturer to blame NASA and NASA to blame the manufacturer. The ensuing investigation soon realized the true errors. The process to determine the actual causative factor was through the use of a root cause analysis (RCA). As in most RCA reviews, there may be more than one specific event that triggers a problem. Often it is found to be several events that combine to create a catastrophic event. By analyzing all components that contributed to the event, the true cause or causes can be determined. This allows for a rational action plan to be formulated for the prevention of future occurrences.
The conclusions demonstrated judgment errors that occurred resulting in the explosion of the Challenger Space Shuttle with loss of lives. A corrective plan of action was formulated and a system to assess the results of the new policies was implemented.[9] Had system processes been in place mandating a specific action to abort the launch when non-routine (change to colder temps than ever experienced before) conditions occurred, the explosion might well have been prevented. Performing a root cause analysis allows a retrospective investigation that brings all contributing factors to light for discussion, review and analysis, and follow-up with corrective action(s).