Friday, April 3, 2009

Lessons from a Sunken Ship

A thing I’ve begun to enjoy about blogging is that it helps me find memories I might otherwise have forgotten and lets me bring people (and pets) into some discussions that might have meaning for you, too. Thanks to all who have sent kind words about Daisy, our dog who is currently receiving hospice care (and recently debuted as the poster child for safe canine medication practices). It’s been a quiet, medicated morning, and I’ve been tooling around the internet and touching base with my parents as I put the finishing touches on the story about ships, Swedes, and safety that I’m sharing today. I hope you’ll enjoy it!

"Those who cannot learn from history are doomed to repeat it."
- George Santayana

On August 10, 1628, only minutes after setting sail on its maiden voyage, the mightiest warship of its time, loaded with a crew of 150, sunk in the Stockholm harbor. The Vasa had been commissioned by King Gustavus Adolphus, Sweden's monarch, who was engaged in a fight with the Poles at the time and desperate to seat a crown jewel in his armada. It’s a well-established fact that the King repeatedly tinkered with the vessel’s design while simultaneously demanding its rapid completion. But these were not the only reasons the Vasa sunk.

Like all disasters, this one had a host of contributory factors setting up the “perfect storm,” that allowed the mighty warship to sink in the Stockholm harbor on a perfectly beautiful, sunny, summer day. An abbreviated but insightful root cause analysis can be found on the official Vasa website. For people who are interested in how culture influences safety, as I am, lessons gleaned from the Vasa are particularly valuable.

It’s relatively easy to see how untested innovation, production pressures, and loss of key leadership contributed to the Vasa’s disastrous voyage. But what's really interesting to me is the Vasa’s failed stability test: In the days before the tragic voyage, the ship had undergone a preliminary test of seaworthiness using the stability testing standards of the day. This involved having a gaggle of men from the shipyard, in this case about 30, run back and forth across the ship’s deck while the ship remained moored. The Vasa’s stability test was halted after just three runs-- long before a satisfactory result was obtained--to prevent the ship from capsizing at the dock.

Nothing further was done to improve the Vasa’s stability before the ship set sail days later.

This sequence of events means that in the interval between the failed test and the maiden voyage, there were at least 30 rank-and-file shipbuilders who knew, who had to have known, that the ship was destined to sink. Do you wonder what they were saying to each other?

I think this particular piece of information captured my imagination when I toured the Vasa Museum several years ago because I know a little something about Swedish sensibilities, having been raised by a first generation Swedish-American whose family flipped back and forth between Sweden and the U.S. in the early 1900’s. Three of my grandparents emigrated from Sweden, and I was born in a small town with a large sub-population of Swedish immigrants. We’re private people, not given to share unsolicited advice (although my cousin once observed that if you sought my father’s advice, he would provide such a detailed explanation that even a novice could fix a Corvair). I joke that if my father asks, “How’s that working out for you?” you’re likely doing something that could cost you a finger.

I don’t know if my father’s sensibilities speak to the culture in the Stockholm shipyard in the 1600’s, and frankly, it probably doesn’t matter. What does matter, and still matters today, is that the Vasa sunk in part because there was no mechanism in place, no recognized, endorsed, or welcomed way, for critical information known by line managers and workers to be heard. My father will help you out, lending his considerable knowledge, time, and skills most generously, but you have to let him know you want to hear from him.

In 2007 (that's 379 years after the Vasa sunk, according to the calculator app in my iPhone), researchers studying how to best identify and respond to healthcare defects giving rise to the epidemic of adverse events that confront us today observed,

“There are many sources to identify defects, including patient safety reporting systems, morbidity and mortality conferences, sentinel events, liability claims, and perhaps most powerfully, asking staff how they think the next patient will be harmed.”1
This concept ain’t an iPhone, folks. Just ask my Dad.

Coming next: Later is better than never (more lessons from the Vasa).

1 Berenholtz, B. & Pronovost, P. (2007). Monitoring patient safety. Critical Care Clinics, 23, 659-673.

1 comment:

Cockroach Catcher said...

Good post. Got it through Grand Rounds.

The Cockroach Catcher

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