1. Disch, Joanne PhD, RN, FAAN
  2. Wakefield, Douglas S. PhD
  3. Wakefield, Bonnie J. PhD, RN


Pilots cannot work double shifts. Why should nurses?


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Have you ever flown on an airplane that didn't have a copilot or a sufficient staff of adequately trained flight attendants? Probably not. Have you ever been on an airline flight that was delayed until some seemingly minor equipment problem was fixed? It's quite likely you have.

Figure. Joanne Disch... - Click to enlarge in new windowFigure. Joanne Disch
Figure. Douglas S. W... - Click to enlarge in new windowFigure. Douglas S. Wakefield
Figure. Bonnie J. Wa... - Click to enlarge in new windowFigure. Bonnie J. Wakefield

Now consider this: have you ever worked on a unit that wasn't fully staffed or that didn't have the proper equipment?


If there's a safety problem, a plane doesn't fly. When will nurses be able to say "It's not safe to have patients on this unit"-particularly when elective procedures may be stretching the hospital's staffing capacity?


The U.S. commercial aviation industry has been a model of safety in recent years, having benefited from decades of examining airplanes that have crashed to determine why the accident occurred and how it could have been prevented. Increasingly, health care organizations are looking to the aviation industry for ways to improve patient safety.


Flight crews-not only pilots-routinely use simulators to practice flying under emergency conditions. The industry has defined clear, consistent roles for all members of the flight crew, and there's zero tolerance for unilateral decision making when group input is needed. Crew members receive rigorous, standardized continuing education, and regulations limit work hours to prevent errors caused by fatigue and overwork. For these and many other reasons, commercial aviation is a highly reliable and safe industry.


In contrast, the health care industry has been plagued by rising error rates and concerns over reliability, quality, and cost. Preventing Medication Errors, a new report from the Institute of Medicine (IOM), estimates that 1.5 million adverse drug events occur in the United States each year (see In 1999 the IOM estimated that 98,000 deaths occurred each year as a result of all types of error. One has to wonder how our health care system can continue to operate without having a commitment to safety comparable to that of the aviation industry. Hospitals certainly know that patient safety is a problem, but too few are making the changes that are needed to create a culture of safety-one that makes patient safety an institutional priority.


Obviously, there are differences between the two industries: being a hospital patient is a vastly different experience from being an airline passenger. Patients often arrive at a hospital in the throes of a medical emergency and health professionals have to exercise judgment in assessing, diagnosing, and treating them. But the aviation industry can teach us things that can be used to make patients safer. For example, leaders in health care could


* establish baseline staffing standards that, if breached, will temporarily close patient units until staffing levels are again acceptable.


* institute continuing education (CE) requirements for all nurses and physicians.


* offer sufficient CE opportunities related to patient safety.


* increase the use of simulation as a tool for helping caregivers develop skills in handling difficult situations, new equipment, and emergencies.


* provide training in communication, conflict resolution, shared decision making, and team building for everyone involved in delivering health care.


* establish guidelines for setting work schedules that reflect current evidence on shift length and other factors.



When a plane crashes and hundreds of people die, it's a horrible event. Yet on a daily basis, hundreds of patients die because of errors in our health care system. The only difference is that the patients are dying one at a time. It's long past time for us to address this question: "Should patients be allowed to fly on this patient care unit?" Let's learn from the airline industry the things that might work for us.