Personal Experience with Medical Error: Missed Concepts & Opportunities

Home » Personal Experience with Medical Error: Missed Concepts & Opportunities

Presented By: Lt. Col. Jerry Both, USAFR (Ret)
September 2018

In aviation an accident is typically the result of a chain of multiple events that lead to a catastrophic result. If you break that chain the accident can typically be prevented. After what was supposed to be a “routine” surgery the patient in this presentation is overcome by a bizarre chain of events that was left unbroken and resulted in his premature death twelve days later. When would you have spoken up? Do you work in a culture that allows you to speak up, to attempt to break the chain? The TeamSTEPPS program was mirrored after aviation’s “Crew Resource Management” (CRM) program. It brings to healthcare a program that allows nurses and other healthcare workers an opportunity to speak up and “Advocate and Assert” on behalf of the patient without the fear of – according to Peter Pronovost, M.D. in Safe Patients, Smart Hospitals – getting one’s “head bitten off.”


In this presentation a commercial airline pilot reviews both CRM and TeamSTEPPS and expands upon the Threat and Error Management principle of CRM. While searching for “threats” care more concepts to adopt from aviation, more than just CRM and checklists.


Your entire healthcare team will benefit from this session so please be sure to tune in.


For OR inquiries, please contact Joann Wortham at (818)545-3343 or

Scroll to Top