From Aviation to Neurosurgery: the 'Inpatient Safety On-Board' (ISOB)

The ISOB Program at the Neurological Institute “C. Besta” Western society is becoming more and more competitive and demanding, where an amateur attitude is considered unacceptable, in almost every aspect of any professional career.

In this context, Neurosurgery may represent a paradigm of a high-risk and high-performance surgical specialty, where no room for improvisation is left, and where Patients constantly demand for better outcomes. Despite all efforts, 3% to 16% of all Patients still experience some unintentional harmful event during their hospital stay. Patient harm is most likely to happen in the operating room (O.R.), which ends up to be a not-so-safe environment for Patients. The problem is: how can we, as Neurosurgeons, create a safer environment for our Patients? In order to answer this question we have to consider how Neurosurgeons are selected, trained and integrated into their working environment. Similarly to what happens in other surgical specialties, in order to become a Neurosurgeon it is necessary to possess a bulk of definite both intellectual and technical skills (which might be defined as “hard-core” skills); besides, there are some less outlined aspects that are also required to be a good Neurosurgeon, which we might refer to as “soft-core” or non-technical skills. According to the CanMEDS document, any doctor should possess and/or develop some extra-competencies (along with being a medical expert, a health advocate and a scholar), which are very similar, for instance, to what is required to be a pilot of the Royal Air Force, namely: confidence and resilience, oral communication skills, problem solving ability and team working aptitude. It is interesting to note that this parallel between aviation and medical/surgical training has been first drawn in the 1950s (trying to introduce risk management programs in US hospitals), but it has never fully developed and implemented yet into clinical practice.

Since 2009, at the Neurosurgery Department of the Neurological Institute "C. Besta" in Milan, we have been focusing on how to transpose that “aviation safety approach” into everyday neurosurgical practice, with special consideration to both risk prevention and risk management. We developed a unique and integrated projector tackle this important issue, the so-called “Inpatient Safety On-Board” (ISOB) program.

This project is the result of collaboration between Neurosurgery health professionals and a group of experts in the field of aviation safety management (including both military and civilian airplane pilots along with an astronaut).Our program integrates both surveys and educational steps with some pro-active, targeted interventions. All in all, the goal of this project is to promote both a basic “safety culture" and an advanced “Crew Resource Management”, which was adapted to the healthcare environment and switched into “Team Resource Management” (TRM). We started this program by initially assessing how the “safety-issue” was perceived by the whole medical crew and especially we analyzed what people knew about safety in Neurosurgery. We evaluated a brand new approach in assessing “safety culture”, by modeling a questionnaire in order to obtain some cross indications related to the various aspects of “safety culture”: Safety culture tout court, Reporting culture, Just culture, Flexible culture, Learning culture, Professional culture.

Our results confirmed that Neurosurgeons were aware of the importance of improving safety levels both inside and outside the O.R. At the same time, their thoughts about this topic were usually confused and inaccurate. We are now going to repeat this assessment after a two-year period of time, to check whether there was an improvement in this regard.