CC Greenberg

DZ Anderson

EL Hoover

Institute of Medicine

MA Makary

Philip F Stahel

RK Michaels

RM Wachter

English

PubMed

Crossref

Learning from aviation safety: a call for formal "readbacks" in surgery

Springer - Publisher Connector

BioMed CentralPatient Safety in Surgery
ssOpen AcceEditorial
Learning from aviation safety: a call for formal "readbacks" in 
surgery
Philip F Stahel
Address: Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, 
Denver, CO 80204, USA
Email: Philip F Stahel - philip.stahel@dhha.org
The first fatal airplane crash in history occurred exactly
100 years ago, on September 17, 1908, when Army lieu-
tenant Thomas Selfridge died in a failed flight attempt
with the aviation pioneer Orville Wright. Since that time,
aviation safety standards have significantly improved.
Currently, the risk for an American dying in an airplane
crash is about 1:500,000, compared to a 1:20,000 chance
of dying in a car accident. In the field of medicine, it was
not until the shocking report by the Institute of Medicine in
1999 revealed that 100,000's of patients die in the United
States every year as a consequence of medical errors [1],
when we began to realize that there is something "wrong
with the system". While this unacceptably high number
has been chronically underrated in public recognition, an
extrapolation of these statistics to professional aviation
equals to about 200 jumbo jet crashes per year, or one 747
crash every other day. This dramatic insight led to the
design of the "100,000 lives campaign" by the Institute for
Healthcare Improvement in 2004 [2]. By 2006, the cam-
paign had surpassed its initial goal by saving more than
120,000 lives through the implementation of increased
patient safety standards and algorithms [2]. These include
the recent implementation of a standardized surgical
"time-out" to ensure the correct patient identity and correct
procedure performed at the correct surgical site [3]. In
addition, the implementation of formal, structured peri-
operative briefings in the operating room have been
shown to significantly reduce the incidence of wrong site
surgeries [4].
Despite those recent improvements, the analysis of the
American College of Surgeons' closed claims study revealed
that a breakdown in communication before, during, or
after surgery still represents a significant source of errors
which lead to patient complications [5]. Of these, 85% of
adverse events related to communication breakdown
occurred by verbal communication, while only 4% were
attributed to communication in written form [5]. This
notion provides the basis for a call for written checklists
and formal verbal "readback" orders among healthcare
professionals who care for surgical patients, in order to
avoid or reduce the high incidence of perioperative com-
plications related to a breakdown in communication.
Interestingly, pilot readbacks represent a hallmark safety
concept in professional aviation. While the current debate
in aviation safety is related to optimizing and correcting
the modality of readbacks [6,7], this crucial form of com-
munication is still virtually nonexistent among surgeons.
Dr. Eddie Hoover has characterized the issue to the point,
in a recent editorial: "Getting surgeons to readback orders and
instructions will age you 10 years, yet the Navies of the world
have demonstrated for eons that it improves efficiency, pro-
motes safety, and saves lives." [8].
I wish to emphasize that the implementation of verbal
readback orders represents the 2nd National Patient Safety
Goal (NPSG) for 2009, as defined by the Joint Commis-
sion [9]. The NPSG #02.01.01, aimed at improving the
effectiveness of communication among caregivers, is
defined as such: "For verbal or telephone orders or for tele-
phone reporting of critical test results, the individual giving the
order or test result verifies the complete order or test result by
having the person receiving the information record and 'read
back' the complete order or test result." [9].
Published: 17 September 2008
Patient Safety in Surgery 2008, 2:21 doi:10.1186/1754-9493-2-21
Received: 3 September 2008
Accepted: 17 September 2008
This article is available from: http://www.pssjournal.com/content/2/1/21
© 2008 Stahel; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 2
(page number not for citation purposes)
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In conclusion, I urge all healthcare professionals involved
in the care of surgical patients to contribute to improved
patient safety and reduced complications and sentinel
events in 2009 by addressing the most frequent root cause
for adverse outcome in surgery: Ineffective communica-
tion. The implementation of formal standardized "read-
backs" is a promising start.
Competing interests
The author declares that he has no competing interests.
Acknowledgements
I would like to thank Ms. Jan Minifie, Dr. Ted Clarke, and Dr. Kagan Ozer 
for helpful discussions related to this editorial.
References
1. Institute of Medicine: To Err is Human: Building a Safer Health
System.  National Academy Press, Washington D.C.; 1999. 
2. Wachter RM, Pronovost PJ: The 100,000 lives campaign: a scien-
tific and policy review.  Jt Comm J Qual Patient Saf 2006,
32(11):621-627.
3. Michaels RK, Makary MA, Dahab Y, Frassica FJ, Heitmiller E, Rowen
LC, Crotreau R, Brem H, Pronovost PJ: Achieving the National
Quality Forum's "never events": prevention of wrong site,
wrong procedure, and wrong patient operations.  Ann Surg
2007, 245:526-32.
4. Makary MA, Mukherjee A, Sexton JB, Syin D, Goodrich E, Hartmann
E, Rowen L, Behrens DC, Marohn M, Pronovost PJ: Operating
room briefings and wrong site surgery.  J Am Coll Surg 2007,
204:236-43.
5. Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR, Rogers SO,
Zinner MJ, Gawande AA: Patterns of communication break-
downs resulting in injury to surgical patients.  J Am Coll Surg
2007, 204:533-40.
6. Anderson DZ: Correcting readbacks.  Aviation Safety 2008,
28(3):3.
7. Correcting readbacks – letters to the editor.  Aviation Safety
2008, 28(4):.
8. Hoover EL: Patient safety and surgeons – why the resistance?
Arch Surg 2007, 142:1127-8.
9.  [http://www.jointcommission.org/PatientSafety/NationalPatientSafe
tyGoals/].Page 2 of 2
(page number not for citation purposes)


Stahel Philip F

Directory of Open Access Journals

Patient Safety in Surgery

Correcting readbacks – letters to the editor. Aviation Safety

Correcting readbacks. Aviation Safety

Gawande AA: Patterns of communication breakdowns resulting in injury to surgical patients.

Medicine: To Err is Human: Building a Safer Health System. National Academy Press,

Patient safety and surgeons – why the resistance? Arch Surg

PJ: Achieving the National Quality Forum's &quot;never events&quot;: prevention of wrong site, wrong procedure, and wrong patient operations. Ann Surg

PJ: Operating room briefings and wrong site surgery.

Pronovost PJ: The 100,000 lives campaign: a scientific and policy review.

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Learning from aviation safety: a call for formal "readbacks" in surgery

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