Queen's Conference Breaks the Code of Silence on Medical Errors

There was an undetectable metallurgical defect the size of a grain of sand in a critical area of the DC-10's fan disk in the tail-mounted engine. The defect caused a fatigue crack which was not detected by the engine overhaul facility. The crack caused the fan rotor assembly in the tail-mounted engine to blow apart during United Airlines flight 232, causing the pilots to lose virtually all control of the plane. The resulting crash landing caused 111 fatalities, 47 serious injuries and 125 minor ones. Thirteen were uninjured.

The story of flight 232 was told at The Queen's Medical Center's "Breaking the Code of Silence 2" conference on safety in medicine, recently held at the Hawai'i Convention Center. All medical professionals throughout the state were invited to attend the day long conference. It was the second conference on safety in health care sponsored by Queen's.

The conference pointed out that the health care industry can learn a great deal from the aviation industry to avoid some of the pitfalls of simply being human. The aviation industry used to have a culture where a captain's orders were not to be questioned, but obeyed. Realizing the dangers of that culture, the industry has been able to change to a culture of openness and a team understanding of what is happening and what is going to happen next.

Speaker Julie Morath, RN, MS, Chief Operating Officer and Chief Nursing Officer of Children's Hospital and Clinics, presented the "Swiss Cheese Model" as an explanation of why errors are made. "There are usually six to eight errors that line up to cause harm," she says. Each part of a system (the organization, profession, team, individuals, machines, etc.) are there to prevent hazards, but are like slices of Swiss cheese, with the holes representing defects (incomplete procedures, inadequate training, production pressures, distractions, etc.). When circumstance pitches a hazard toward the barriers in a direction where all the holes line up, an accident occurs.

As Hawaii's health care leader, The Queen's Medical has brought the issue of safety in medicine to the forefront, and is committed to the oath of every conscientious medical professional and physician: "first, do no harm."