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Commentary on “House Staff Participation in Patient Safety Reporting: Identification of Predominant Barriers and Implementation of a Pilot Program”

Turi McNamee, MD
Volume: 109 Issue: 7 July, 2016

Abstract:

In his book Outliers: The Story of Success, Malcolm Gladwell describes a dark period in the history of Korean Air, which had experienced more crashes than almost any other airline.1 After investigation it was found that in many of these crashes, the copilot/first officer had grave concerns before the crash that often were disregarded, if they were voiced at all. Investigators posited that the barriers to communication in the cockpit many times were substantial enough that they either silenced the copilots or rendered their voices of warning unheard. Business suffered and people died. The company then embarked on a targeted intervention designed to overcome the barriers to communication in the cockpit, and the crash rates plummeted (irony unintentional). Dispute over the origins of the communication barriers aside, one fact remains: When key players on a team are not heard, bad things happen.

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References:

1. Gladwell M. Outliers: The Story of Success. Boston: Little, Brown, 2008.
 
2. Stewart DA, Justin J, Adams MA, et al. House staff participation in patient safety reporting: identification of predominant barriers and implementation of a pilot program. South Med J 2016;109:395-400.
 

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