Dear Editor,

I read with interest the recent Intensive Care Medicine editorial entitled “Protocols: help for improvement but beware of regression to the mean and mediocrity” [1].

I wish to support the authors’ comments highlighting how the use of protocols can lead to improvements in care and outcome, but I have serious concerns with the suggestion that these can not be successfully applied to advanced and experienced organisations and providers. There are echoes of the hubris of medicine as described by Atul Gawande [2].

Girbes et al. reference the benefits of a well-designed checklist for central venous catheter (CVC) insertion [3], yet then continue to illustrate how a badly designed checklist may not be effective, overlooking that this is the result of poor design rather than the use of a checklist.

Checklists are designed to support and complement professional decision-making [4] and as such are critical to improving our outcomes. They are an effective method of creating institutional knowledge.

I have serious concerns that this editorial may result in misconception of the importance of human factors integration into healthcare systems. This is illustrated by the misrepresentation of the Hudson aircraft landing. This landing was not achieved by “knowledge of aeronautics, his skill as a pilot, and his intuition” as stated in the editorial. It was achieved by a pre-flight briefing by two pilots who had never previously flown together, clear communication, the co-pilot running through a series of checklists including that for ditching in water as they were losing altitude, use of the aircraft fly-by-wire system, a high-performing crew and their skills as pilots [5].

It is essential that we as a profession are prepared to ditch our hubris, accept that reducing variation requires a compromise of professional autonomy, stop hiding behind an apparition of human complexity and save our expertise for the relatively rare scenarios in which it is required and then use it in conjunction with well-designed decision support. This is how we will start to really improve our performance.

Sullenberger’s own words following the Hudson incident are worth consideration:

“Everything we know in aviation, every rule in the rule book, every procedure we have, we know because someone somewhere died…We have purchased at great cost, lessons literally bought with blood that we have to preserve as institutional knowledge and pass on to succeeding generations. We cannot have the moral failure of forgetting these lessons and have to relearn them.”