Zero tolerance policies toward adverse outcomes during labor and delivery: don't forget about the pilot.

The publication in January 2009 of an article entitled “A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population,” by Haynes and colleagues in the New England Journal of Medicine,1 set off another round of recommendations for airline industry panaceas for our health care system. The Washington Post extolled the lifesaving effects of “a basic cockpit-style checklist in the operating room,” noting that “[s]urgeons ... are discovering what airline pilots learned decades ago ... .”2 Similarly, Toronto’s The Globe and Mail proclaimed “[a] simple operating room checklist, similar to the one pilots use in the cockpit before takeoff, can dramatically reduce major complications in patients and even save lives, according to a just published study.”3 Interestingly, the same day that the New England Journal of Medicine article hit the news services, US Airways Flight 1549 crashed into the Hudson River just minutes after taking off from New York’s LaGuardia Airport. All 155 people aboard were evacuated safely from the stricken aircraft. Reflecting on this miraculous outcome from a potentially disastrous situation, newspapers and the public universally singled out the pilot for his efforts. “I don’t think there’s enough praise to go around for someone who does something like this. This is something you really can’t prepare for,” said former Delta pilot Denny Walsh.4 “You really don’t practice water landings in commercial airplanes. Just the sheer expertise he demonstrated is amazing.” “It would appear that the pilot did a masterful job of landing the plane in the river and then making sure that everybody got out,” said New York City Mayor Michael R. Bloomberg.4 Although checklists and simulators will surely enhance patient safety, let us not forget the pilot. For difficult surgeries, complicated labors, or vexing medical dilemmas, someone who knows what to do is still a key component to achieving the best outcome. Effective systems are necessary, but not sufficient for patient safety. We must continue to aggressively recruit the best medical students, to train them in superb residency programs, and to maintain their skills through effective continuing medical education programs.

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