Career Achievement Safety First

Whether in space or in the operating room, James Bagian is committed to eliminating deadly mistakes.

Mr. James Bagian found himself in disturbingly familiar territory in February, when he was called on to help investigate the loss of the space shuttle Columbia. It had been 17 years since Bagian dove 95 feet into the Atlantic Ocean to find the remains of friends and colleagues who perished aboard the shuttle Challenger.

This time around, there were no blue waters to search. But Bagian's mission was the same: View the evidence, analyze the data, figure out what went wrong and, most importantly, help NASA determine how to prevent such a tragedy from ever occurring again.

It's what Bagian does. It's what he has done his entire federal career. From redesigning ejection seats on Navy fighter jets to reduce injuries to his current work of eliminating medical mishaps at Veterans Affairs Department hospitals, Bagian has focused on one thing-creating a culture of safety.

That wasn't always his plan, though. "When I was 8 years old, as a Cub Scout, we had to make a scrapbook about something," Bagian, 51, says. "I did mine on the space program. That was when [Alan] Shepard was the first person to fly into space. I knew I wanted to be an astronaut." But three years later, Bagian relinquished the dream, momentarily. "I was 12. I thought no one actually gets to be an astronaut. Look at how many people are in the U.S. Look at how few astronauts there are."

Instead, Bagian, who grew up in Philadelphia, the son of a World War II fighter pilot, opted to study engineering, because he was attracted to the problem-solving aspect of the field. He earned a degree in mechanical engineering from Drexel University in his hometown. But after apprenticing for various companies during his studies, Bagian was discouraged by the fact that seniority played a large role in how people were promoted.

Bagian looked for a profession where he could become master of his destiny, and settled on medicine. Upon completing his engineering studies in 1973, he enrolled at Thomas Jefferson University, also in Philadelphia, to pursue a medical degree. Before classes started, he spent the summer earning a pilot's license.

Throughout his career in government, Bagian has found ways to put his unusual combination of engineering and medical degrees to use. One of the earliest examples came while he was working as an engineer at the U.S. Naval Test Center in Patuxent River, Md., in 1976. Bagian, who was still in medical school at the time, learned that one-third of pilots who ejected from fighter planes suffered fractured vertebrae. He realized that the problem was the jerk of acceleration pilots experienced when they first ejected. He devised a new system to slow the rate of acceleration while still providing a safe exit. The system is standard in Navy jets and has dramatically reduced injuries.

Yet Bagian couldn't fight the urge for space travel. He applied to become an astronaut in 1976. He didn't hear anything for about a year. Then, while completing rounds one June night in 1977 at Geisinger Medical Center in Danville, Pa., his beeper sounded. It was NASA. He was one of 20 people chosen that year to be astronauts.

Bagian was set to fulfill his childhood dream in 1987, when he was named to serve on the crew of the Challenger to perform a scientific mission. But five months before the scheduled launch, NASA shifted priorities and decided to go with a crew trained to deploy a satellite. As the Challenger lifted off, Bagian sat in the NASA command center, serving as the flight medical officer.

When the shuttle exploded just over a minute after launch, Bagian, a trained diver, was among the group of people sent out to search for survivors.

During the ensuing investigation, Bagian was instrumental in pushing for new safety measures. Most notably, he led the effort to redesign the shuttle's crew cabin to include an escape hatch. Using his engineering skills and knowledge as a physician, he developed pressure suits and parachutes that would allow future astronauts to float to Earth safely from a high altitude.

Unfortunately, Columbia's crew did not have time to use the escape hatch. But Bagian, who served on the Columbia Accident Investigation Board, says he hopes NASA will consider improving the "skin" of the crew cabin in the shuttles, so that the cab could withstand the heat of re-entry to the Earth's atmosphere. That way the crew could use the escape hatch once the module reached a lower altitude.

For all of the publicity and high drama that comes with working on the space shuttle, Bagian says the most important challenge of his career came in 1998, when he agreed to head the National Center for Patient Safety at the Veterans Affairs Department. His assignment was daunting-completely overhaul the culture at VA medical centers to make patient safety the top priority. Minimizing errors in treatment has long been a source of frustration in the medical community, because of a culture that has tended to focus on blame rather than problem-solving. As a result, many health care professionals are loath to point out mistakes or near misses.

The issue reached a critical point in 1999 when the Institute of Medicine released a study estimating that between 44,000 and 98,000 Americans die annually from preventable medical mistakes. The institute recommended that the government and hospitals create a system to report and track errors.

The VA was already looking for ways to improve safety. Under the leadership of Veterans Health Administration chief Kenneth Kizer and, later, Thomas Garthwaite, the agency developed a patient safety program in 1997. But it lacked a point person for more than a year. Finally, Kizer asked Bagian to take the helm and, in 1999, turned the program into a permanent part of the VA, creating the National Center for Patient Safety.

In Bagian, the VA found someone who would become the driving force for patient safety. The center encourages VA health care professionals to report errors and near misses. More importantly, though, it requires them to figure out where and why communication breakdowns result in errors.

The approach is paying dividends. Between January and August of this year, the VA had yet to record an incident of incorrect surgery-in which the wrong patient is operated on or the wrong surgery is performed on a patient. In prior years, the VA's 170-plus hospitals usually would have experienced at least eight incorrect surgeries during that time span. The VA also has led the field in developing new coding systems to ensure that drugs are distributed appropriately.

Garthwaite credits Bagian with the center's success. "James is contagious and infectious," he says. "He is so down to earth. When he talks about the specifics, things just come to life."

Bagian is forging a partnership with private hospitals, hoping to bring them along on his quest for quality. Don Nielsen, senior vice president of quality at the American Hospital Association, says Bagian walked into a difficult situation and immediately put people at ease. He helped the health care community rally around a simple goal: Do no harm to the patient.

"I took this job because it was the right thing to do," Bagian says. "It's been the most satisfying thing I have ever done."

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