Thursday, October 29, 2009

Why a trick is still a treat

Yesterday morning, I found and posted what I thought was a great video clip, one that seemed to say all the things I am struggling to articulate in an article about healthcare culture and what happens to safety efforts when people don't report errors.

On first pass, the events captured on film jumped out at me, as the old expression "a picture's worth a thousand words" promises they will. An errant SUV, out of control for a split second, crushes two vehicles in the adjacent row of a parking lot. Amazingly, the SUV recovers, backing off of its unlucky neighbors. The video captures a brief latency, during which time one imagines the driver reflecting upon the situation and considering what to do next. Then, the vehicle slinks away, leaving viewers to judge the actions of the driver based upon what we've just seen.

I did. It looked like a vehicular telling of what I recognized, from very early in my career, as unacceptable behavior that might be excused, especially if the driver hadn't made mistakes like this in the past or had a reputation for using the errant vehicle to do good things (like deliver medical supplies to poor people). The owners of the affected vehicles might have had the damage explained in a "collateral" kind of way: These things happen when one chooses to park in a public lot and other disclaimer language, such as what's found in the "limits of liability" fine print on a parking ticket.

Mostly, I saw the lost opportunity to learn what had caused the vehicle to suddenly lose control. How did what appeared to be a routine parking manuever suddenly turn so sour? In the slinking away, I saw the opportunity to acquire information go missing. Information that, if shared, could help others avoid making a similar mistake. Did the driver mistake the brake for the gas pedal? Was he texting at the same time he was trying to park? Or did he wake up that morning and say, "By God, I think I'm going to see if I can dry hump a couple of cars on my way to the dentist?"

But enough about the lessons that could have been learned. There's another, more authentic one for people interested in cultivating a climate that promotes safety, a lesson I figured out when I demanded my son (a new driver) watch the video with me. It turned out that what I thought I had seen didn't make sense in the third or fourth viewing. The superficial "facts" (visible to everyone who views the incriminating video) don't add up. Post-hit, none of the vehicles exhibit any damage and the position of the passive vehicles in the aftermath of the event don't square with the events that one "sees" happening.

So what this video, still a great learning experience, really illustrates is the importance of moving beyond what we believe is readily apparent when investigating the root cause of error events.

People on Twitter are buzzing about the airliner that overshot the Minneapolis-St. Paul airport last week, with tweets like this being the norm:
Too late now but the #NWA188 pilots implausible story is worse for their careers than the likely truth (Zzzzz)

But this approach (that also came in the form of a tweet) shows a better way to get beyond perceptions and beliefs: Missed by 150 miles? And there are cool tools that help front line clinicians become fluent in proactive risk reduction activities, too.

It's fun to speculate about what went wrong when high profile mishaps hit the news cycle or appear to happen right before our eyes. But healthcare leaders who investigate errors and plan risk reduction strategies, benefit from using the same methodologies that FAA and NTSB professionals do.

And that's the safety lesson that really jumps out from the tricky little YouTube video.

Happy Halloween!

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