Blockchain Papers

Naxhelli Ruíz Rivera

Resumen. Este artículo analiza la implementación de un esquema de reducción de riesgo de desastres asociados a la actividad petroquímica en la ciudad de Coatzacoalcos, en un contexto de descentralización de la gestión de riesgos. El trabajo aborda el papel de las asociaciones público-privadas y el ambiente institucional en torno a las labores locales de protección civil y gestión de riesgos. El artículo identifica los ámbitos de acción de agentes públicos y privados, y analiza el marco legal, los acuerdos políticos informales y las regulaciones fuera del ámbito legal que permiten la colaboración de estos agentes. El estudio muestra que la funcionalidad de estas asociaciones se basa en formas de confianza y colaboración que no tienen como base los principios del marco normativo establecido por el Estado y los acuerdos internacionales en la materia. El estudio concluye que los beneficios y derechos adquiridos a través de redes personales constituyen el apoyo central de este ambiente institucional. Abstract. This paper analyzes the chemical hazards-related disaster risk reduction (drr) scheme in the petrochemical industry oriented city of Coatzacoalcos (Mexico) in the context of political decentralization. This work addresses the role of public-private partnerships, as well as the institutional environment around civil protection and chemical risk management. The paper identifies the scopes of action of public and private agents, and analyzes the legal framework, the informal political agreements and the non-legal regulations that allow these agents’ collaboration. The study shows that the functionality of these partnerships is based on forms of trust that do not rely entirely on the normative framework established by State organizations and international agreements; the trust that underlies their schemes of collaboration is relatively autonomous from the bureaucratic side of this institutional environment. The study concludes that the benefits and rights accessed through personal networks are the core of the institutional environment around risk governance.

Rita Peihua Zhang, Helen Lingard, Steve Nevin

Construction organizations are large and complex with decentralized structures, and characterized by non-routine work undertaken by semi-autonomous work groups. Construction workers’ perceptions of safety climate can form at different levels and vary between subunits. A multilevel safety climate measurement tool was proposed, which identified five important safety agents, i.e. client, principal contractor, supervisor, co-workers, and individual workers. Surveys were conducted at three construction projects commissioned by Fonterra Co-operative Group. A total of 356 participants completed the survey. The data was subject to scale reliability analysis and factor analysis. The results showed that all scales achieved satisfactory internal consistency and the multilevel factorial structure was generally supported. At the organizational level, the tool measures clients’ overall safety priority and safety actions, and principal contractors’ general commitment to safety. At the group level, the tool measures supervisors’ safety actions and safety expectations, and co-workers’ general safety values and practices. The tool also measures individual safety responses reflected by safety compliance and safety participation. The measurement tool would help construction organizations to diagnose potential weaknesses in their safety management practices for safety improvement and also help to develop a social and cultural work environment that is supportive of safety at all levels.

David M. Gaba

The healthcare industry may be the largest and most expensive endeavor of the developed world, with the United States at the top of the list of per capita expenditure. Clearly, as indicated by the intense (and continuing) debate over the Affordable Care Act, the issues of the healthcare industry are of extreme interest to the public and policy makers.The biggest problems in the healthcare industry are about how to achieve its fundamental goals—how to provide adequate and equitable care to the entire populace; how to guarantee equitable access to all; how to achieve optimal population health; how to ensure efficacy, quality, and safety of patient care; how to provide choice of provider and hospital; and, most importantly, how to pay for all of these goals and how to obtain political agreement of the populace to make it happen.Fortunately, this monograph will address primarily issues of quality and safety, and will largely ignore these other very large and thorny issues. Some of the ideas in this chapter have been addressed in part by the author in prior journal publications.12From a safety standpoint, it is now well recognized that there is a significant incidence of harming patients in the course of trying to diagnose and treat them.3Many such events are known to be preventable. The incidence of minor problems is very high, but even serious events have been found in approximately 1% of all hospitalizations. It is often said that many of these adverse events are irrelevant because the patients they occur in are already very ill, and hence might well have suffered negative outcomes anyway. However, I contend that no patient “signs up for bad care,” so we should still be very concerned about such events even when they do not, in the final analysis, actually affect the final outcome. The next time, maybe they will.In addition, it is likely that many errors that occur, even serious errors, are hidden. Some are not apparent because the patient is very ill, so only detailed investigation or analysis can disclose an error. In other cases, errors can be hidden simply by failing to inform anyone of them and waiting to see what happens. Moreover, healthcare does not have the robust incident or accident investigation processes that are routine in transportation (e.g., National Transportation Safety Board). Most investigations—in the infrequent occasions that they occur—are conducted only at the local level and with varying degrees of sophistication and alacrity.Parts of healthcare (such as anesthesia and surgery) and nuclear power production are but two examples of activities of “high intrinsic hazard” (aviation is a well-known third). The hazard in these activities is inherent—it can be managed and controlled—but the hazard cannot be eliminated. Yet, the management of hazard in nuclear power and aviation has become so good that it is accepted that adverse events are not “normal.”Nuclear reactors should not unexpectedly interrupt power production, and they should never harm workers or the public, melt down, or explode. Airplanes are not supposed to crash—ever. In these arenas when one of these things happens, we know that something went horribly wrong. Yet, human beings are inherently prone to catastrophic internal failures that result in serious disability or death. Thus, adverse outcomes—not necessarily due to errors or poor care—are very common in healthcare. All of us are going to die, and most of us will die in close proximity to healthcare. It is difficult to sort out which events are the ordinary “natural history” of disease and which are due to suboptimal care. This makes efforts at measuring safety outcomes particularly difficult in healthcare.All of the high intrinsic hazard industries share the fact that they are so critical to human welfare that we cannot just shut them all down while we solve all of their problems. Certainly, we can't stop performing healthcare activities just because they are imperfect—the ravages of disease are worse. While a single nuclear reactor can be shut down whenever necessary, and a flight can be cancelled or delayed, it is sometimes impossible (and possibly unethical) to refrain from or abort an emergency medical procedure due to a significant safety risk when the patient's underlying disease processes will otherwise quickly cause serious harm or death.Decisions on a larger scale are more complicated. While it is in principle possible to abandon the use of nuclear power in some countries, this can only be done temporarily or it must be phased out over a very long period of time. Access to abundant electrical power is the lifeblood of modern societies. Similarly, the dislocations caused by even short stoppages of air travel by the 9/11 terrorist event or the Icelandic volcano's ash cloud demonstrated that air travel also cannot be stopped for long. On the other hand, in healthcare, the introduction of new, potentially lifesaving drugs and devices can be delayed pending proof that they are safe and effective.The calculus of such decisions may vary from country to country, although many aspects of healthcare (and nuclear power production) are similar everywhere. In healthcare, the practices of physicians stem originally from the roots of the “autonomous healer” who used individual, often idiosyncratic, knowledge and “skill” to diagnose and treat ailments. There were few curative or invasive therapies. While administering potions to, cupping, and bleeding patients didn't usually help them very much, and might have hastened their demise, they were not generally powerful enough to directly cause serious harm or death. Hospitals were originally organized more as “guild workshops” 4 wherein the members of the physician's guild could independently ply their trade.Now, in the early 21st century, some things have changed drastically while others have not. We have many more diagnostic and treatment interventions that can often cure. Many are very powerful and can themselves directly, and quite quickly, cause serious harm or death. I like to say that there is a high potential lethality per square meter in settings like the operating room, intensive care unit, emergency room, or chemotherapy administration unit. Wielding such interventions requires very complex care coordinated across many individuals and many work units.Since the latter half of the 20th century, it has become possible to compare many patient outcomes in response to diagnosis or treatment, a process that is still unfinished. Despite all of this change, the structure of the hospital, for example, has not changed much in hundreds of years, retaining many elements of the guild workshop. Even where an institution is the employer of physicians, the amount of autonomy of practice given to physicians is enormous, despite the grumblings of how medicine is dictated by the rules and regulations of payers and other bodies. The system also is structured around assumptions that the individual skill of the professionals will be uniform, solid, and unvarying over time, which of course is impossible to guarantee.Even the division of labor is old. I conjecture that if healthcare were to be developed now, from scratch, we would not have job types of “doctor,” “nurse,” “pharmacist,” and “respiratory therapist,” to name only a few. We would have many other job types and a vastly different organizational and work structure—hopefully based on a more rational assessment of how best, and how safely, to achieve the goals of the work in the first place.A fundamental difference in healthcare versus other industries is that “we” do not design or construct the units we work on: human beings—nor are we given an instruction manual for them. We do not understand a great deal of how the human body works, how it fails, or why and how it gets sick or recovers from illness. Yes, great strides have been made and more discoveries are happening every day, but we are mostly working empirically by trial and error.In my own field of anesthesia, we do not know many of the fundamental mechanisms by which our drugs can render patients unconscious, unaware, resistant to pain, immobile, and (fortunately) unable to recall what has transpired during surgery. Yet, by trial and error, we have worked out the methods to do these things—which clearly evolution never really intended for human beings—on a regular basis with low, but not low enough, rates of serious problems.In healthcare, the public is very concerned with personal and intimate aspects of the work, and such individual, societal, and ethical issues are commonplace. They also care very deeply about choosing and seeing “their” doctor. This is not the case for other industries where the public doesn't care specifically who exactly is doing the work (pilots and nuclear power plant operators interact with the public minimally, if at all). However, for nuclear power, the public has great concerns over the long-term impact of accidents, and also a hard to grasp “dread” factor of radiation that does not come into play in healthcare.56Organizationally, the nuclear power industry and healthcare are very different. There are just over 100 nuclear power reactors in the United States, owned and operated by 30–40 firms and under significant scrutiny by the federal regulator, the U.S. Nuclear Regulatory Commission (NRC).Healthcare is a vastly more decentralized and massive undertaking. There are 4,000– 6,000 hospitals, owned by 1,000–2,000 firms. There are roughly the same number of stand-alone surgicenters. There are more than 200,000 physician offices. More than 20 million surgical operations with anesthesia are performed, just under one billion doctor visits occur, and about three billion prescriptions are written every year in the United States. Yet, there is no federal regulatory agency of the practice of healthcare. That comes under the jurisdictions of the 50 states and the federal health systems (e.g., Department of Defense, Department of Veterans Affairs, and the Indian Health Service).The federal U.S. Food and Drug Administration regulates the approval and sale of drugs and devices. The federal Centers for Medicare & Medicaid Services (CMS) controls the criteria for federal payment for medical services. CMS may act as an indirect regulator of practice—if you won't get paid for it, you probably won't do it—and there are other indirect regulators by accreditation (e.g., The Joint Commission) or by voluntary participation (e.g., Institute for Healthcare Improvement and the Leapfrog Group). However, indirect regulation is generally not comparable to direct regulation, as in the NRC's direct oversight of nuclear power, or the Federal Aviation Administration's direct oversight of aviation.Of note, in aviation and nuclear power, the firms themselves (individual airlines or individual power utility companies) impose strong safety control over the day-to-day work of personnel, often over and above the requirements of the regulator. This is only partially true for healthcare. The work of nurses, pharmacists, and allied health personnel comes under the direct purview of the employing institution, although the degree to which actual practices at the front line reflect the stated goals or policies of the institution varies greatly.The practices of physicians have less direct oversight by the firm; the majority of physicians are independent (fee-for-service, not salaried) members of the hospital's medical staff. As such, though not under direct line authority of the hospital, they must apply for clinical privileges and their actions can be scrutinized by the institution. Other influences on physician practices come from specialty board certification and professional society practice guidelines.However, when guidelines are well articulated, strongly evidence based, and widely agreed upon by the medical community, it typically takes a decade until these practices are consistently adopted and executed. Regardless of whether physicians are actual employees of the hospital or are independent medical staff members, in practice they have nearly unlimited discretion as to how they manage individual patients. Local standardized operating procedures are occasionally imposed, but even then their authority and compliance may be minimal, especially without specific incentives for compliance or disincentives for noncompliance.In fact, all of the hazardous industries suffer from a phenomenon in which what is articulated for safety on paper does not always correspond to the reality at the front line or even to a plausible reality that could be implemented at the front line. One aspect of this has been described by the sociologist Lee Clarke as “fantasy documents,” such as policies, procedures, or plans that are created to satisfy a regulatory, internal, or public relations need, but are known by most participants to be infeasible. They “sound good” and make people feel better, but it is widely known—at least by frontline staff—that they cannot really work as described.78One factor about the aftermath of accidents that affects other industries in a profound way that doesn't happen in healthcare is that a severe accident in nuclear power, in oil refining, or even in aviation, can seriously harm the “means of production.” That is, not only may the accident hurt workers or the public, it also takes out of service the facilities (power plants, refineries, or airplanes) that are used to do the work. Even ignoring cleanup or repair costs (if relevant), this means that there is a huge financial and operational loss from the lost means of production.As indicated above, for nuclear power, this can expand all of the way to long-term plans to abandon this method of generating electricity. None of these effects is seen in healthcare. If we harm a patient in the operating room, that may be very sad, may generate litigation, and may (rarely) garner bad publicity for the hospital, but we just “send for the next patient.”I cynically suggest that if the aftermath of medical errors or preventably suboptimal care events in an OR, ICU room, or emergency department bay would be to take that room out of service for days or months, that would generate a much more aggressive response for improvement by the healthcare institution than we currently see.It is true that healthcare cannot strive for the same level of standardization within a facility, or especially between facilities having the same basic technology, as is achieved in nuclear power or the aviation industry. Human beings are not reactors or airplanes and diseases are not understood at fundamental levels, hence healthcare personnel need more flexibility to respond to unanticipated situations. However, as for many things in healthcare, the pendulum is currently too far to the side of insufficient standardization.On the equipment and procurement side, the decentralization and huge number of sites of care raise all sorts of issues. Unlike the 106 nuclear power plants of perhaps a few dozen designs, the hundreds of thousands of patient rooms, ORs, ICU bays, etc., in the 8,000 institutions each needs outfitting with various devices such as monitors and infusion pumps.Rather than being purchased as large, integrated, preconfigured units, such devices are often purchased one at a time, or, at best, in periodic bundles of hundreds. The combinatorics of all of the devices makes it impossible for vendors to test them in use all together. And, until fairly recently, there was little demand on vendors—either from regulators or the marketplace—for serious human factors testing of either prototypes or actual devices.The decision to purchase equipment is often made by small committees or single influential individuals based on idiosyncratic assessments of features. Purchase decisions are strongly affected by the purchase cost of the equipment and disposable supplies, and only rarely by total life cycle or systems cost. One area where both nuclear power and healthcare can benefit is to achieve and maintain a high degree of user-centered human factors testing of concepts, prototypes, and actual equipment during the design, premarketing, marketing, and postmarketing phases of product life.Issues of design are compounded in healthcare by the current variability in the preparation and training of personnel on the use of the equipment, even that which is life critical. Nursing and allied health disciplines generally have more structured mechanisms for providing training to personnel before they use advanced equipment via “in-services” and checkoffs of competency.Even so, experience suggests that such checkoffs can be “fantasy activities”—showing that immediately after training, and in a quiet environment, a clinician can demonstrate performance of specific tasks doesn't necessarily correlate with skill with the device during actual use in challenging real-life conditions. Fortunately, most of the time, personnel do rapidly learn to use the essential aspects of equipment in their routine bedside activities.However, problems may arise especially for devices that are used only rarely (e.g., defibrillators), in situations requiring the use of advanced and complex device features, or when it is necessary to deal with unexpected glitches or faults (e.g., when something isn't hooked up quite right or the wrong button is accidentally pressed) in a stressful in physicians have been more resistant to to training, which is rarely made Thus, it is not for a physician to a device a anesthesia in patient having never or seen or used the healthcare, there is like the in aviation, of how much experience has as an they cannot an they have been specifically and as on that of In nuclear power, each plant has a of the control room on so it is that plant operators would be to control the reactor and systems if they are not with the this suggests that perhaps healthcare nuclear power have the optimal structure for In healthcare, it is and with little devices and systems are In nuclear power, there is strong control and little risk of by but at the cost of extreme and to especially in safety critical in so many there may be a in the Clearly, to its and physician autonomy and control by firms or but has to up to its for very high Nuclear power has an safety at least in the United States, but is, to a in its not of and other the two in many there are many of where of and may each industry to a that is more and at cost to the

David M. Gaba

It is a fact of history that many of us who pioneered simulation in healthcare took as inspiration the experience of other intrinsically high-hazard industries such as commercial aviation. Many of us have argued forcefully that healthcare should adopt simulation comprehensively in part to follow the model set by these industries. Yet, with simulation in healthcare having some roots that go back decades, and with even aviation-inspired curricula in healthcare (like ACRM) approaching 20th anniversaries (ACRM was first offered in September 1990) one can wonder why the healthcare industry has not embraced and implemented simulation as fully as has been done by other industries including commercial aviation, the military, or nuclear power. I would like to explore this analogy a little more deeply, reviewing what I see as the meaningful similarities, as well as the profound differences, between healthcare as an industry and these other risky human endeavors, focusing especially on commercial aviation. This paper is a combination of my own personal recollections and an objective assessment of the industries. Some elements of this analysis are taken from my paper Structures and Organizational Issues in Patient Safety: A Comparison of Health Care to Other High Hazard Industries (California Management Review, Fall, 2000)1 while other aspects come from the talks I have been giving in the last 7 years. The Flight Deck as a Cognitive Parallel for Dynamic Healthcare Settings A little known point about my own laboratory's development of the mannequin-based simulator in the late 1980s was that we started with the goal of creating a tool for the understanding of cognition of anesthesiologists in the handling of adverse events. We were driven to this by our analysis of the “chain of accident evolution” in anesthesia – the ways in which inciting triggers end up as major catastrophes if not interrupted by the intervention of the anesthesiologist. We made a number of conjectures about cognition in these settings: “To recover from anesthesia incidents, the anesthesiologist must: 1) detect one or more of the manifestations of the incident in progress; 2) verify the manifestations and reject false alarms; 3) recognize that the manifestations represent an actual or potential threat; 4) assure continued maintenance of life-sustaining functions; 5) implement “generic” diagnostic or corrective strategies to provide failure compensation and allow continuation of surgery if possible; 6) achieve specific diagnosis and therapy for the underlying causes; and 7) provide follow-up of recovery to ensure adequate correction or compensation.”2 To provide empirical data to confirm these conjectures we needed a way to provide standardized adverse events to different clinicians to tease out the typical response behaviors. My own background as an avowed “aviation and space nut” stood me in good stead, giving me the knowledge of the existence of simulators in these arenas. That led us to create the CASE simulator series initially for this cognition research.3 Our experiments were described in several papers appearing in Anesthesia and Analgesia.4–6 As we looked for models in medicine of such dynamic decision making processes we didn't find them. Most of the literature on medical decision making were about quite static decisions, and concerned highly mathematical and probabilistic techniques that couldn't readily account for the behavior of anesthesiologists that we had observed. But we did find models for such cognition in other industries, particularly aviation. The flight deck of the aircraft does have a number of cognitive parallels with that of anesthesia and other medical domains, such as intensive care or emergency medicine. In all such settings most time will be spent in ordinary and routine activities. Like in the operating room, even in a busy ICU or emergency department the true crises will be rare. Hours of boredom, moments of terror is a mantra on the flight deck as well as in the operating room. A “flight” has many similarities to “an anesthetic.” Each has a phase of preparation – analysis of the situation (weather versus underlying diseases) – and equipment checks. Take off is like induction, cruise is like maintenance, and landing is like emergence. Certain flights, and certain surgical cases have key midstream milestones that must be anticipated and planned for. On both the flight deck and in the operating room there is a plethora of information sources, some of them mutually redundant, requiring dynamic allocation of attention but allowing cross-checking between sources. Our own research had shown that anesthesiologists did not solve acute problems by direct application of deep abstract reasoning but rather by applying “precompiled” knowledge, doing the usual things about the usual problems. Aviation does the same thing except they have codified many of the responses into an emergency procedures manual; pilots are expected to know from memory the first few items of these procedures, but to use the written protocols themselves for anything further. Both commercial flying and healthcare are conducted in crews and teams. We consider a crew to be one or more individuals each from a specific discipline, sometimes with their own hierarchy; multiple crews working together makeup a team. The flight deck crew are pilots (the days of nonpilot flight engineers in a 3 person flight deck are almost gone) with a “Captain” and “First-Officer”. The flight deck crew combine with the cabin crew to make up the aircraft team, and the team is larger still when air traffic control, airline dispatch and maintenance are included. Similarly, the OR has a surgeon crew, a nursing crew, an anesthesia crew, and sometimes specialist technicians (like cardiopulmonary bypass perfusionists). The crews work together as a team. Aviation found that intracrew and intercrew coordination was a major feature of good problem solving and that failures of coordination were at the root of many accidents.7 We also felt, by introspection, that a substantial part of expertise in anesthesiology lay in the ability to coordinate the anesthesia crew members (whenever there was more than one) and in the ability to coordinate with the other crews, especially the surgeons. Given these similarities, it is no wonder that we believed intuitively then, and still do now, that it was worth adapting many practices of aviation for use in healthcare. The use of simulation in aviation has been extensive, both for teaching practical “stick and rudder” skills but since the mid 1980s, also for the so called “nontechnical” skills known as Crew Resource Management (CRM).8,9 Having first heard about CRM possibly in an episode of the PBS show NOVA called “Why Planes Crash” we were fortunate that one key architect of early CRM worked at the nearby NASA Ames Research Center. This contact facilitated our exposure to the CRM approach allowing us to rapidly adapt many elements of CRM into a simulation-based curriculum for anesthesiology (ACRM). The wide spread of the simulation-based CRM approach within anesthesiology and across health care disciplines and domains has been gratifying to watch. Clearly, the resonance that we perceived between the cognitive and social psychologic aspects of work on the flight deck with that in the hospital has been shared by thousands of others. Nearly 20 years down the line in applying aviation concepts to health care, I still stand by the marked parallels at the level of the “sharp end” work itself. The dynamic thinking of people in dynamic fields of health care is much like that of pilots (and where it isn't yet, it probably should be closer). The 2 activities are not the same of course. Patients are not airplanes. Some aspects of health care are intrinsically different from aviation because of this fact. Other aspects are different not because of an intrinsic difference in the work but rather because of differences in the organizational structure of health care as an industry versus air transport as an industry. Let me explore some of each kind of these differences. What Does It Mean That Patients Are Not Airplanes? A major feature of the notion that “patients are not airplanes” is that people don't design and build human beings whereas they do design and build airplanes. I like that say that no one provides the instruction manual for humans. These facts mean that the level of uncertainty about human beings is enormously greater than that about airplanes. Each plane of a given type will behave in nearly the same fashion given the same small set of key characteristics (eg, thrust, weight, altitude, angle of attack) whereas the diversity between human beings is enormous. Designers instrument airplanes to give key data that can be relied on to fly the plane, whereas in health care clinicians typically obtain a smattering of data (eg, blood pressure, ECG, oxygen saturation) from noninvasive external sources. Airplanes are usually in good shape when we fly them, and there aren't mechanics in the back working on the aircraft during a flight, liable to sever a hydraulic line or the like. A daily variable in flying is weather and in this regard has some parallel to the routine diversity of “patient acuity” that we deal with in health care. Still, in commercial flying if the weather is bad enough, the planes don't fly regardless of how badly the passengers need to get where they're going. In health care, if the surgery is important enough it must go ahead regardless of whether the underlying disease state poses a danger. Another consideration is that health care is very personal. Most people don't care who the pilot of their airliner is as long as she or he is good at the job, and we don't care if the same pilot flies us on one leg of our trip as on the next leg. But we do care a lot about our physicians and having a personal relationship with physicians is perceived to be very important. Moreover, health care is full of issues of social norms and ethics that rarely enter into the sphere of aviation. Organizational Differences Between Healthcare and Other Industries Integration and Economies of Scale: Both aviation and health care are extremely decentralized, in contrast to some other high hazard undertakings that have been studied extensively (like aircraft carriers, of which the entire world has only 20, in the hands of but a few nations' navies). Annually in the U.S. there are more than 11 million departures by large airlines and somewhat over 30 million surgical procedures (the actual number is hard to come by), a roughly comparable figure. Both endeavors are conducted at hundreds or thousands of sites scattered all across the nation, some very large, and some relatively small. In this respect the industries are comparable. But whereas only about 10 airlines are responsible for the 11 million flights, the surgical procedures are conducted at (on the order of) 4,000–6,000 hospitals and a similar number of standalone surgicenters (not to mention office-based surgery). These are owned by on the order of 1,000 – 6,000 firms (no one really knows the number of firms; there are some large hospital chains, but most hospitals are one or 2 of a kind). The small number of firms gives airlines a huge economy of scale and it greatly simplifies both official and unofficial safety regulation of the industry. A good safety idea, even if not an official “de jure” regulation, can be adopted by the industry nationwide if 10 firms think it is worth doing. In healthcare one would have to convince each one of the many thousands of firms. There are a few examples of very large integrated health care organizations in the U.S (the Veterans Affairs health system is one and Kaiser Permanente is another; both have had much publicized safety efforts). Whether safety is actually greater in such integrated systems than in any nonintegrated collection of institutions of similar size, diversity, and scope remains to be seen, but it is conceivable that a system with some of the economies of scale and integration like that of the airline industry could come into being and demonstrate safety benefits of such organization. Accidents and the Means of Production The rates of fatal accidents in these industries is markedly disparate. Between 2002 and 2006 there were on the order of 10.5 to 11.5 million departures on major airlines (Part 121– see http://www.ntsb.gov/aviation/Table5.htm) with between 0 to 3 fatal accidents killing 0–50 people (median about 20). This yields rates of fatal crashes on the order of 0.020 per 100,000 departures. In healthcare we do not know the rates of fatal accidents so clearly. An airplane is never supposed to crash, and when it does it is highly public and may harm dozens or hundreds of people. When it comes to health and disease, all humans are destined to die, and in the industrial world nearly all will die in proximity to healthcare activities. Sorting out those that were due to accidents and those that were due only to the natural course of disease is difficult. Further, healthcare accidents are hidden and usually harm only one person. Still if taking the most wildly optimistic estimates of healthcare success – say the rate of fatal accidents due only to anesthesia care for healthy patients having routine surgery, which are on the order of 0.5 deaths per 100,000 cases,10,11 healthcare is still 25 times more dangerous than flying. For healthcare as a whole the gap is probably considerably larger. In aviation and other hazardous industries accidents harm workers and often the public, are highly publicized by the media, generate lawsuits, and (cynically) of even more concern is that a catastrophic accident destroys the means of production. In such a case the airplane (or even worse in the power industry, a power plant) is removed from service and has to be replaced at great cost and disruption. This gives even the hard-hearted “bean-counters” a healthy interest in avoiding accidents. In healthcare by contrast, accidents or other episodes of suboptimal care harm a patient but do not (generally) harm workers or the means of production. When clinicians hurt a patient they may feel bad about it but then they send for the next patient scheduled for that site. The recent announcement by the major U.S. government payer for healthcare (Centers for Medicare and Medicaid Services) that it will no longer pay for certain preventable conditions, mistakes or infections resulting from a hospital stay is a slight step in the direction of greater “business reasons” to avoid accidents, but even so the means of production are left intact. Imagine how much more seriously this would be taken if every time there was a serious problem in care in the OR or ICU that site had to be taken out of service for a year. Regulation In the U.S. a single federal agency regulates air transport, and comprehensively oversees nearly every level of equipment, personnel, and detailed operations all the way down to some flight crew processes. Beyond the official regulator there is a national independent agency (the National Transportation Safety Board) that investigates accidents and makes safety recommendations to the regulatory body. The firms themselves exert strong control over the pilots with standard operating procedures and company policies that are strongly adhered to. In health care, while a federal agency regulates drugs and devices, it does not regulate the practice of medicine. Each of 50 states and 3 federal jurisdictions (Department of of Veterans and the Health regulates the practice of medicine. The level of government regulatory control is and in it is very (or at the level of actual firms only over the practices of There is no independent official safety for health care. There is regulation by like the a level of regulation such is to for for as from government the some healthcare institutions not to be by the and even the of this agency has been in the as being relatively The has more assessment procedures, especially in relatively the hospitals often know in that is in the level of control by such regulation is still rather In some have with somewhat from the perceived by many or to the model of work for The of In this model the hospital like a in which the independent members to do their The did not any level of control over the the have done some hospitals do to safety that to I have been in several such are but the level of organizational and control are and at Many of the organizational in health care come from more than years and some are But the of health care work has greatly in this there was often little harm physicians could do to patients and other of were probably but rarely in and of in many settings the per is quite The of and high medical care may not well to organizational from over the years there has been some of and the of how healthcare is for has the work of physicians is one of the most activities of intrinsically risky human A substantial of and is in the system because human beings are not airplanes or nuclear power Healthcare does not need to achieve the same level of and control that these industries. But the in in my is quite to the other and to a is an important goal on the to safety and and Differences between the industries on the structure and of and are also The major airlines in the U.S. on other systems to flight airlines in the world flight taking pilot from experience and doing all the In the many pilots from the is – pilots working their way up in the then airlines to the in both systems is but it is not so much on the of of underlying knowledge but rather more on the of actual and The airlines have highly to and to their own and is by the and by the government – it can be done in a airliner or in a the simulator is a and On of this is a of assessment of pilots by the government both during and during actual Healthcare at the level of on and but not on for the by a long of of concepts and then by an of or taking care of patients of) What one on which patients in the during and the of the specific members as When very or crises the are out of the way so that can the There is little with of with a (and of for physicians the can be by a wide diversity of few of them or on issues of or patient These differences, like most of the other organizational differences are not intrinsic to the fact that patients are not airplanes. Healthcare could use the same of and to assure the and of The is a of and not the or consideration of how to achieve the by some the healthcare system could be from it would probably be and it much more like some of the other high-hazard industries. In I sometimes wonder – thinking about my own of anesthesiology – whether things would have been different had flight been in and anesthesia only in rather than the other way it isn't to the healthcare system from first must be made while the and organizational elements of the system intact. This is one of the key to the processes of simulation-based and assessment we in aviation. has been made in the last years from such industries, but it will the of this approach are fully in healthcare. of this will be in this but I have over more than 20 years that we had have a lot of and a long in