Editorial: All I really need to know I learned from an air traffic controller

August 1, 2005

Now consider this scenario: It's 2 AM on a busy L&D unit. A 26-year-old G2 P1, whose primary physician is on vacation, arrives in active labor and with no prenatal chart. The covering physician's sign out report does not mention that the woman's first delivery was complicated by a neonatal clavicular fracture. The harried and exhausted resident does take an oral history and notes it in the chart. But he forgets to tell the attending, who can't read his handwriting. Also not available on admission is the lab report of an abnormal glucose screening result and normal 3-hour glucose tolerance test, or an U/S done 3 days ago that revealed an estimated fetal weight of 5,100 g. The unit clerk dutifully files these vital pieces of information, but never verbally brings them to the attention of those providing direct care.

The patient is admitted with an estimated fetal weight of 9 lb and has been tested to 8 lb in her prior delivery. She stands 62 inches, has a body mass index of 35, and her pelvis feels adequate. Her protracted active labor is treated with oxytocin and her second stage is 3 hours. The delivery is complicated by a 3½-minute shoulder dystocia refractory to all initial interventions, which is ultimately resolved by extracting the posterior arm. The result: an infant with humeral fracture and a permanent Erb's palsy and lawsuits against both the covering and original obstetricians.

In the airline industry, Crew Resource Management (CRM) programs, which seek to prevent human error-associated air crashes, are now the standard. Developed in 1979, CRM emphasizes the role of human factors in high-stress, high-risk environments.1 The programs teach all members of the team how to point out safety concerns and help heighten awareness of how stress and fatigue impact performance. On the tarmac, any member of the team-from the baggage handler to the pilot-can stop a plane from taking off.

In medicine, too, communication plays a major role in errors. More than half of all medical errors are at least partially attributable to communication problems, according to a 2000 report by the Institute of Medicine (IOM).2 Nearly as many errors are attributable to inadequate orientation and training, says the IOM. That's not at all surprising, considering that health-care providers are expected to work in teams but receive their education and training separately, in virtual "silos." The segregation extends to continuing medical education, morning rounds, and evening sign-outs. Think for a moment about how many different individuals are involved in a single delivery: physicians, nurses, midwives, sonologists, pharmacists, phlebotomists, lab technicians, scrub techs, etc. Yet how many of us has ever received a lecture about how to communicate with our colleagues? Very few, if any.