Lost Luggage

"Please raise your hand if you never check your luggage when you fly," I asked the audience.

Several hands went up immediately.  I motioned towards a woman in the audience and asked, "Why don't you check your luggage?"

"Because I have to pay $25-50 each time,” she replied.

"Fair enough.  But you can afford that right?"  The woman nodded in response, so I asked again, "So, if it's not about the money, what is the real reason that you never check your luggage?"

"I am afraid the airline will lose it," she replied.

"Has that ever happened to you?" I asked.

"Maybe once a few years ago," the woman replied.

While the exact sequence of questions probably didn't happen exactly as I described (the story is apocryphal), I have often asked a similar question whenever I have been talking to groups about patient safety with a similar response.  As it turns out, according to a survey of more than 570 airline passengers conducted a few years ago, about 20% of passengers always carry on their luggage (nearly 30% of passengers say they always check their luggage).  Considering that over 4.5 billion passengers flew in 2019, that means that 900 million passsengers every year carry on their luggage.  When you further consider that, at least according to the Bureau of Transportation Statistics, the 15 largest airlines in the United States make about $3.5 billion in total revenue from baggage handling fees, there is clearly a lost opportunity for additional revenue by encouraging more passengers to check their luggage.

So how often do airlines really lose your luggage?  In general, it happens about 2 to 3 times per 1,000 passengers.  An obvious question follows - why accept this rate of failure when it represents a potentially significant opportunity to generate additional revenue?  Indeed, 20% of all passengers absolutely refuse to accept this degree of failure rate, and close to 50% will carry on their luggage depending upon their specific circumstances (say, for example, if a passenger has a tight connections - and doesn't want to take a chance on the airlines losing the luggage in transfer!).

If a significant percentage of the general public refuses to accept a failure rate on the order of 2-3 per 1,000 for something as minor (at least in the grand spectrum of things) as lost luggage, then why are we in health care willing to accept this kind of failure rate for things that are arguably much more important, i.e. things that have an impact on patients' lives?  Actually, when you compare apples to apples (passenger deaths due to airline accidents versus patient safety-related deaths), there's really no comparison!  Every time that you fly, there is a 1 in 3 million risk of dying.  Compare that statistic to a 1 in 300 chance of dying from a preventable medical error!   

Multiple studies report that 10% of patients suffer from an adverse event while in the hospital, and approximately half of these adverse events are preventable!  Let's take a look at some more specific rates of failure compared to the rate of lost luggage (these statistics are from the National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015):

Catheter-associated Urinary Tract Infections:  8.2 per 1,000 hospital discharges

Falls:   6.7 per 1,000 hospital discharges

Pressure Ulcers:   36.3 per 1,000 hospital discharges

Central Line associated Bloodstream Infections (CLABSI): 0.05 per 1,000 hospital discharges

Surgical Site Infections:   2.5 per 1,000 hospital discharges

Hospital-acquired C. difficile infection:   3.1 per 1,000 discharges

Overall, with the notable exception of central line infections, hospitals compare quite poorly to airlines and their "lost luggage" failure rate.  This kind of failure rate is not acceptable for airline passengers, and it shouldn't be acceptable for patients admitted to our hospitals either!  More concerning, despite several years of hard work and focused attention on these hospital-acquired conditions, we aren't really getting that much better.  Clearly we have some work to do.  Perhaps we need a change in focus - or at least a change in attitude.

Even now, some of these conditions are viewed by many as "the cost of doing business" - if your hospital is taking care of really sick patients with a lot of chronic conditions, your hospital is going to experience these kinds of hospital-acquired conditions.  That attitude MUST change!  There are enough examples of hospitals who drive down their rates of these conditions and continue to take care of the sickest of the sick patients.  

There are approaches that we can take.  I've written a lot of posts in the past on high reliability organizations.  We need to learn from other health care organizations that are on the journey to high reliability, as well as industries outside of health care (like commercial aviation - but looking at their accident rate and not the lost luggage rate).  I wholeheartedly believe that this is the right kind of approach, and we will talk more about high reliability organizations in the next post!