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Aviation and surgery are both high-stakes, complex fields that require precision, teamwork, and effective communication to ensure safety and optimal outcomes. The aviation industry has long been recognized as a model for safety and reliability, with a focus on standardized protocols, rigorous training, and a culture of continuous improvement. In recent years, there has been growing interest in applying the principles and practices of high reliability organizations (HROs), such as those found in aviation, to the field of surgery.
Dr. McCormick has the unique experience of flying Fighter Jets in the US Navy and Marine Corp, including working with and learning from the nation’s elite fighter pilots. He has taken those extremely valuable “Lesson’s learned” as in now applying them to his surgical practice. For over a decade now, Dr. McCormick’s practice has utilized the key principles of aviation and HROs and applies them to yield improved surgical safety and outcomes.
1. Standardization and Checklists
One of the hallmarks of aviation safety is the use of standardized protocols and checklists. Pilots and crew members follow a set of well-defined procedures for every phase of flight, from pre-flight checks to landing. These checklists ensure that critical steps are not missed and that all necessary equipment and systems are functioning properly. Similarly, HROs rely on standardized processes and checklists to reduce variability and minimize the risk of errors.
2. Crew Resource Management
Aviation places a strong emphasis on teamwork and effective communication, known as Crew Resource Management (CRM). CRM training focuses on developing skills such as leadership, situational awareness, decision-making, and communication. Pilots and crew members are trained to work together as a cohesive unit, with clear roles and responsibilities. They are also encouraged to speak up if they notice any potential safety issues, regardless of their rank or position.
3. Simulation and Training
Aviation professionals undergo extensive training and simulation to prepare for a wide range of scenarios, including emergencies. Pilots spend countless hours in flight simulators, practicing normal and abnormal procedures, and honing their skills. This training allows them to develop muscle memory and to respond quickly and effectively in high-stress situations. HROs also place a strong emphasis on training and simulation, recognizing that practice is essential for building expertise and resilience.
4. Incident Reporting and Analysis
Aviation has a robust system for reporting and analyzing safety incidents and near-misses. Pilots and crew members are encouraged to report any safety concerns, no matter how minor, without fear of retribution. These reports are then analyzed by safety experts to identify trends and potential hazards, and to develop strategies for prevention. HROs also have systems in place for reporting and analyzing incidents, recognizing that every event provides an opportunity for learning and improvement.
5. Just Culture
Aviation promotes a “just culture,” which balances accountability with a non-punitive approach to error reporting. In a just culture, individuals are not punished for honest mistakes or errors, but are held accountable for reckless or intentional violations of safety protocols. This approach encourages open communication and a focus on system-level improvements, rather than individual blame. HROs also strive to create a just culture, recognizing that punitive approaches can discourage reporting and hinder learning.
1. Surgical Safety Checklists
The use of surgical safety checklists, modeled after aviation checklists, has been shown to significantly reduce complications and mortality in surgery. The World Health Organization (WHO) Surgical Safety Checklist, for example, includes 19 items that are checked at three critical points: before anesthesia induction, before skin incision, and before the patient leaves the operating room. The checklist ensures that critical steps, such as patient identification, site marking, and equipment checks, are not missed. Studies have shown that the use of surgical safety checklists can reduce complications by up to 36% and mortality by up to 47%.
2. Teamwork and Communication
Effective teamwork and communication are essential for safe and efficient surgery. Like aviation, surgery involves a complex interplay of professionals with different roles and expertise, including surgeons, anesthesiologists, nurses, and technicians. Breakdowns in communication and coordination can lead to errors, delays, and adverse events. Applying CRM principles to surgery can help to improve teamwork and communication. This may involve training in leadership, situational awareness, and assertive communication, as well as the use of structured communication tools such as SBAR (Situation, Background, Assessment, Recommendation).
3. Simulation and Skills Training
Simulation-based training is increasingly being used in surgery to improve technical skills, teamwork, and crisis management. Like aviation simulators, surgical simulators allow trainees to practice procedures and scenarios in a safe, controlled environment. Simulation can range from simple task trainers to high-fidelity virtual reality systems. Studies have shown that simulation training can improve surgical skills, reduce errors, and enhance patient safety. In addition to technical skills, simulation can also be used to practice non-technical skills such as communication, decision-making, and situational awareness.
4. Incident Reporting and Analysis
Incident reporting and analysis are critical for identifying and addressing safety issues in surgery. However, underreporting of adverse events and near-misses remains a significant challenge. Applying aviation-style incident reporting systems to surgery can help to encourage reporting and facilitate learning. This may involve creating a non-punitive reporting culture, providing feedback to reporters, and using data to drive system-level improvements. Root cause analysis, a structured method for investigating incidents and identifying contributing factors, can also be applied to surgical adverse events to identify opportunities for prevention.
5. Safety Culture
1. Creating a strong safety culture is essential for applying aviation principles to surgery. A safety culture prioritizes safety above all else, encourages open communication and reporting, and fosters continuous learning and improvement. Leaders play a critical role in shaping safety culture by modeling appropriate behaviors, setting clear expectations, and providing resources and support for safety initiatives. Applying just culture principles can help to balance accountability with a non-punitive approach to error, encouraging reporting and learning.
While the application of aviation principles to surgery holds great promise for improving safety and outcomes, there are also challenges and limitations to consider. Surgery is a highly complex and variable field, with a wide range of procedures, patient populations, and settings. Standardization and checklists may not be applicable or sufficient for all surgical situations. Additionally, the hierarchical culture of medicine, with its emphasis on individual autonomy and expertise, may resist the adoption of team-based approaches and standardized protocols.
Another challenge is the resource-intensive nature of some aviation-style interventions, such as simulation training and incident reporting systems. Implementing these interventions may require significant investments in technology, personnel, and infrastructure. There may also be concerns about the medicolegal implications of incident reporting and the potential for increased liability.
Finally, it is important to recognize that aviation principles are not a panacea for surgical safety. While they can help to reduce errors and improve outcomes, they cannot eliminate all risks or complications. Surgery will always involve some degree of uncertainty and unpredictability, and adverse events will continue to occur even in the best of circumstances.
The application of aviation principles and high reliability organization within Dr. McCormick’s surgical practice holds great promise for improving safety, efficiency, and outcomes. Standardization, checklists, teamwork, simulation, incident reporting, and safety culture are all key elements of the aviation approach that we are adapting to the surgical setting. While there are challenges and limitations to consider, the potential benefits of applying these principles are significant and beginning to yield benefits in our patients as evidenced by our: reduced complications, improved patient outcomes, and enhanced learning and improvement.
As the field of surgery continues to evolve and face new challenges, it is essential that we look to other high-stakes industries for guidance and inspiration. By learning from the successes and failures of aviation and other HROs, we continuous aim to create a safer, more reliable, and more patient-centered surgical system. Therefore, we are committed to continuous process improvement; a willingness to challenge traditional ways of thinking and working; and a collaborative effort across all levels of the surgical team and healthcare organization.
Ultimately, the goal of applying aviation principles to surgery is to create a culture of safety and excellence that prioritizes patient well-being above all else. By embracing these principles and practices, we can work towards a future where every surgical patient receives the highest quality care, every time.
©2025 Dr Frank McCormick All Rights Reserved.
©2025 Dr Frank McCormick All Rights Reserved.