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LIFEWINGS "TIP OF THE MONTH" - April 2010 |
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Better Teams. High Reliability Systems.
Sustained Culture Change. |
Over the past few months, I've faced a new challenge as I work to
apply aviation techniques and tools in health care. It usually goes
something like this: "Why should we
pursue aviation-based culture when the airline industry has crews
that fly 150 miles past Minneapolis?"
My response usually begins by noting that even though
some of the information has been made public, very few informed voices
have actually been heard in the mainstream media. James Reason, professor
emeritus at Manchester University and author of the book "Human Error",
perfectly predicted the response from the FAA, the airline, the media, and
the general public. That response was basically, "Hang the guilty bastards."
Dr. Reason warns us that blaming individuals is our reflexive response
because it is easy and emotionally satisfying. If we simply get rid of the
careless and incompetent practitioners then this will never happen again.
Sound familiar?
Suffice it to say
that an intelligent response to human error requires a systems approach to
analyzing what happened, what interventions will prevent reoccurrence of the
error, and only then, taking appropriate actions such as training, policy
changes, and perhaps punishment.
Solution:
The only way we know what happened in this incident,
as well as the numerous non-incidents that occur every day as discussed
above, is that the cockpit crew fully disclosed exactly what happened and
did not obstruct the investigation in any way. In fact, this culture of open
communication is what provided the resilience necessary to prevent a more
serious outcome than the flight landing safely and less than an hour late.
How does your organization
encourage such transparency? Implementing a thoughtful
incident reporting and response algorithm that includes the following
questions, is a great place to start.
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Was the behavior other than what one would reasonably expect in this
situation?
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If so, was it due to ignorance or a simple lapse of memory?
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If not the above, was it due to negligence, recklessness, or willful violation
of regulation, procedure, or protocol?
Results:
This system is not intended to eliminate individual
accountability. It is a transparent system designed to mitigate the impact
of, and more importantly learn from and reduce, individual error. While this
open disclosure begins with debriefing (read
March's Tip of the Month), a reporting culture raises awareness of
latent error in systems and processes and helps avoid embarrassing outcomes.
. . or worse.
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