Happy Meals do not strategy make

Last Monday I lamented the mid-August start of school in Georgia. What I really meant to say was, beware of Happy Meals.

Not that there's anything inherently wrong with standardizing, simplifying, and packaging so that it's easy to get a hold of stuff. "Happy Meals" happen when efficiencies used to deliver predictable results in a reliable fashion are applied to food. And it's certainly nice to give toys to children.

But, as I used to tell my children, the prize associated with a meal is supposed to be food. It makes the gnawing feeling in your stomach called "hunger" go away. That is your present.

As childhood obesity takes stage as a significant public health concern, Happy Meals are being called out. We're beginning to question whether reliable access to high-fat, low nutritional value food is a good thing.

People like me, who fed Happy Meals to our kids once in awhile, probably recognized that these meals weren't served from the table of bountiful harvest. But the short term benefit of a quick meal and minimal clean-up exceeded any longer-term consequences we were reasonably able to anticipate. Who among us knew that so many kids were eating so much junk so frequently? Who would have guessed that Type 2 diabetes would become a childhood illness? Who could have known that the burgeoning weight of American kids would render pediatric drug dosing reference guides, based on growth tables from a previous generation, obsolete?

This is why strategy must be separated from the processes used to make it through the day: we plan meals better when we're not hungry. Strategic planning is about coming to the table, not to eat, but to think about what should be served up and how the pantry should be stocked.

Coming next: Part 2, Happy Meals in healthcare.

California is full of bad actors

California is full of bad actors. But maybe I should tell you something you don't already know.

In case you missed it last week, California's Governor Schwarzenegger replaced most members of the State Nursing Board. This action followed an LA Times report detailing the board's inability to evaluate and rule on allegations of professional misconduct by registered nurses in a timely fashion. A day or two later, two California state senators announced they were crossing party lines to author legislation that would reform the state's Medical Peer Review process. Both actions were widely reported under headlines forecasting improvements in "patient safety."

These initiatives--and others focusing on the processes used to evaluate and re-evaluate professionals who may be "bad actors"--are indeed part of the fabric that protects the safety of patients. But equating occasional long reaches down a dark foxhole with "patient safety" is a huge disservice, a distraction almost, relative to what the science of patient safety really is and what it takes to get the job done.

Patient safety is really the science of reliability applied to healthcare: How does a system operationalize processes in order to achieve a stated goal? It's not "How to cure cancer?" but rather, "How do we ensure that a patient is not killed by an overdose of chemotherapy while undergoing treatment to be cured of cancer?"

Goals like these rely on competent individuals, but they are not achieved--in a reliable fashion--solely because of them. (Having a sober pilot does not guarantee a safe flight.) Measures that focus on individuals' performance and behavioral choices should not be equated with the full spectrum of activities needed to improve the reliability of healthcare.

As healthcare reform ramps up, patients and professionals should be looking for measures--and funding--to enhance patient safety that are wider than a foxhole and constructed in a way that allows existing tunnels to connect.

Meaningful use: Don't pee on my leg and tell me its raining

Standardizing and automating processes within a complex system makes the system more reliable, that is, more likely to produce an expected outcome. This is a core principle of system design although one infrequently taught to front line healthcare professionals, most of whom came-of-age in an intention-based ethic.

If Mr. Rogers were explaining what it means to come from a culture of intention , he'd say, "Can you say, 'The Five Rights of Medication Administration?' or 'Hippocratic Oath,' boys and girls?" But I'm not channeling Mr. Rogers here. This is a Judge Judy day.

Judy Sheindlin, you may recall, is the TV judge and author known for her sharp-tongued assessment and analysis of problems, most of which arise from choices made by imperfect humans and result in less-than-desirable outcomes. Judge Judy pulls from a strong personal moral center, but her opinions are informed by years as a family court prosecutor in New York City.

So what advice might Judge Judy offer to stakeholders who are about to get $20 billion dollars from the American Recovery and Reinvestment Act of 2009 to develop IT solutions that have meaningful use? I'm thinking it should start with, "Don't blow it!" and include a lot of input from front line clinicians.

To date, efforts to automate healthcare processes in clinical settings have produced, on a good day, variable results, especially when compared to what others (like Walmart, Chili's, AirTran, and hell, even Thrifty Car Rental) have achieved. This doesn't mean that automation doesn't work. It means that automation, like every other human endeavor, will rarely produce a desirable outcome spontaneously. (Or as my dad would say: "Fail to plan, plan to fail.")

Few, if any, health IT solutions in the public domain today were built on a strong patient-centric scaffolding, one that saw creation of a static stream of data to and from front line clinicians as a key objective. IT vendors have produced many satisfactory products and solutions. But their wares evolved in response to a market demand for piece-meal solutions, many arising in a reactionary fashion to address narrowly defined needs or mandates. We're now trying to satisfy a champagne appetite for high-stakes patient information that's been built on a beer pocketbook.

Making the patient the center of IT endeavors has the potential to make patient data the default output. And patient information is what professionals closest to the secretions need most to produce reliable outcomes: current medication histories; real-time medication profiles; provider orders; lab results; alarms signaling that an at-risk-to-fall patient has left the bed; that pharmacy-review of medication orders has occured; that an off-service test has been scheduled; that a patient is allergic to this food but likes that one; that an infusion is complete; DNR status; the list goes on.

Today's healthcare IT solutions are like puzzle pieces, with inter-operability specifications (enabling pieces to interlock with one another) in their infancy. Absence of shared platforms & standards may confer a competitive advantage to vendors in an unregulated marketplace, but it's the practical reason why your lab computer system often doesn't "talk" to your pharmacy computer and why patients admitted for community acquired pneumonia may receive a double dose of antibiotics when the ER's system doesn't "talk" to the inpatient system (an outcome, by the way, that standard quality reporting doesn't capture or penalize, but one that's not good for patients, not good for pocketbooks, and one that wouldn't be endemic with more robust communication systems.)

Front line clinicians often aren't enthused by the net effects of healthcare IT, and it's not because they don't recognize and enjoy the benefits of technology while grocery shopping, booking a vacation, or downloading music. But when patchy automation increases complexity and decreases efficiency--outcomes opposite those that normally found with tech-mediated solutions--don't blame the victims for not loving what torments them. Or, as Judge Judy would say, "Don't pee on my leg and tell me it's raining."

With $20 billion and a mandate to create IT solutions that result in meaningful use, maybe success can be measured by the whether the front line wears dry pants.

A touching tribute

Happy Mother's Day! It's a good day to talk about feelings, continuing Flo & Bo's series of daily posts honoring nursing sensibilities.

I became a nurse because I was fascinated with birth, the highly complex process that allows one person to emerge from the body of another. On Mother's Day, we celebrate important relationships that happen in the aftermath of birth, few as straightforward as the creative act itself.

I come from straight-talking women, and I'm fortunate to be my mother's daughter. My maternal grandmother understood complicated things about birth and birth-control, offering on-point observations that included "a drop's as good as a cupful." (Country-woman wisdom that carried a microbiologist's understanding of conception.) But my grandmother's knowledge didn't necessarily inform her personal situation: I'm descended from her 7th child, a change-of-life baby who came along when my grandmother longed to have a driver's license, not another baby.

She managed to get both.

My mother had something of an "auto-pilot" upbringing, which was probably characteristic of the way children born in 1935 and trailing their next-oldest sibling by a decade were raised. She emerged with a concrete, sequential outlook, a way of thinking and organizing data that is best evidenced by the neatly written, color-coded files and lesson plans she maintained throughout her long, distinguished career as a public school teacher in Pennsylvania. In a word, my mother is reliable.

"Auto-pilot" was not the style of parenting my mother used when it was time to raise her children, though. In the house where I grew up, if someone said they'd pick you up following an after-school activity, they did. If you had a doctor's appointment, someone took you to the doctor. When the phone rang, someone answered it.

My mother isn't dogmatic. She doesn't do things for the sake of doing them nor does she do everything herself. Not everything makes it onto my mother's "to do" list. But when it makes the list, it gets done. (She once wrote, "relax, have fun in sun" on the list of things my husband and I were assigned to do in the days preceding our wedding, an entry that we--not fully understanding the mind of a concrete, sequential person--found both humorous and somewhat disturbing. Twenty-two years later, my mother stands by her decision to put "have fun in sun" on the list.)

Thank you for letting me grow up knowing what reliable looks like, Mom! I wouldn't be "the nurse with an engineer's mind" that I am today without you!

Bo with her highly reliable parents.

Flo & Bo say "Hello"!

Happy Nurses' Week! Each day this week, Florence dot com, a real-time patient safety primer, is going to celebrate nursing sensibilities, recognizing the key role you play in making patients safe.

This patient safety blog is named for Florence Nightingale because I wanted it to reflect the kind of advocacy Nightingale did, advancing health and healthcare with a keen eye on the realities front line clinicians face. I hope you'll enjoy this week-long tribute to how you, the descendants of Florence, continue to make patients safe.

Florence Nightingale is often associated with the post-World War II "nurse-as-doctor's-helper" figure that populated novels, TV shows, and ads as baby boomers and Gen-Xers grew up. But this image was more about how women in that era were seen than about nursing, Nightingale-style.

I often use this picture when I speak, noting that nurses used to kneel down, pledging our intention to do good, right, and just things in our professional capacity. Most people laugh, readily identifying the most obvious things that have changed: that apron, that cap; that position, that hairstyle, and the fact that they're both women.

But while a deeply felt desire to "do right" by patients remains a stronghold of nursing, it's worth noting that pledges are now supported by emerging practices and norms, offering increasingly reliable ways for caring people to turn good intentions into desired outcomes.

I hope you'll visit every day in the coming week, find the tributes and take-aways helpful, then subscribe to Florence dot com. To appeal to your senses, here's what Flo & Bo have in store:

Thursday, 5/7: Can you hear me? Can you hear me now?
Friday, 5/8: Do you see what I see?
Saturday, 5/9: Something smells good
Sunday, 5/10: A touching tribute
Monday, 5/11: While it's sometimes tempting to eat the young, here's a better recipe
Tuesday, 5/12: Happy Birthday, Miss Nightingale!

Feel free to use the comment section. It's your party!

Nuts!

Peter Pronovost may think we're nuts. Actually, he said doctors and nurses work in a system that's nuts. But, I'll toss off the virtual nurse's cap this morning, and offer the same advice I'd give to my kids: Nutty is as nutty does.

Pronovost, a well-respected patient safety advocate and practicing clinician, appeared in a Wall Street Journal blog post a few weeks ago, sharing his views about safety gains that could arise from hospital-industry-regulatory collaboration modeled on aviation partnerships. Advocating for measures that transcend what professionals closest to the secretions can pull out of their, well, shall we say, personal supply cabinets, Pronovost pointed out that clinicians who work in hospitals need better and more effective tools to prevent mishaps.

If an infusion meant to be delivered to the epidural space can kill a person if it's inadvertently infused intravenously (as has tragically occurred many times in the past), safest practice would be to make epidural tubing incompatible with the cousin ports populating the patient's nearby IV tubing. An engineered device constraint is far more likely to prevent patient harm than reminding clinicians who manipulate the lines to "be more careful" and placing labels on tubes and lines. Especially when the therapeutic care environment looks like this:

photo used with permission

Personal diligence and adjuvant labeling shouldn't be abandoned, but a constraint like incompatible tubing is a far more effective way to derail a significant error that has been set in motion.

If you've been following Flo's posts for the real-time patient safety lessons she offers, it's worth reviewing the medication use process, recalling that the likelihood of catching (and correcting) an error increases the further upstream the error originates. This makes sense since an error in the prescriber's order has the potential to be picked up by the person who dispenses the drug, the person who administers the drug, or the patient.

Slide based on modeling described by James Reason

Tubing misconnections are errors that originate downstream, in the administration node, meaning there are limited opportunities to uncover them and prevent harm before they reach a patient. Engineered incompatibilities between epidural and intravenous line ports and connectors are powerful constraints, one of the few reliable ways to catch wrong-route errors arising from a clinician's slip, trip, or lapse at the point of medication administration.

When cross-functional stakeholders join forces in healthcare, as they have in aviation, your patients may be as safe while giving birth in the U.S. as they are while flying commercial.

This is not what I envisioned when I became an intrapartum nurse some years ago, but apparently what I should have been saying all along is, "I'm the SafetyNurse, fly me!" (My husband says I've been cleared for take-off, but he may be saying something unrelated to this topic. In any event, I hope you'll travel safely!)

Human Factors

The bi-weekly nursing blog carnival, Change of Shift, is up over at Emergiblog. I love the name "Change of Shift" because the view of healthcare that emerges there, like a Change of Shift hand-off, provides a window into the system we use to deliver care. The realities faced by clinicians on the front line are good reads for anyone interested in understanding the physical and mental challenges involved in providing care, and these accounts show how much relationships matter.

I especially loved a post by Drug Pusher (and not just because I have a keen interest in medication safety!).

The summary of nurses' views about barriers to providing safe care at Better Health is definitely worth reading, especially for people working to develop health IT products. I have an untested hypothesis that goes something like this: Few industries interested in producing reliable results or maintaining strong financial performance would support "humans babysitting machines" to the extent that we currently see in healthcare. Watching "safety" fight with "efficiency" is like watching "healthcare" fight "education" for scarce resources. These are not "pick one" issues. "Nurses dish on communication lapses that harm patients" seems to support my hypothesis.

I hope you'll visit Change of Shift every other Thursday: it's a good place to benchmark practices and keep an eye on emerging trends.

Next up: Deconstructing an error-prone IV medication set-up in a pediatric patient. Review Part 1 here.

Get ready to cancel the launch!

In Lessons from a Sunken Ship, I recounted the story of a 1628 shipwreck that occurred in the aftermath of a failed stability test, a test result known to at least 30 shipbuilders (who nearly put the Vasa underwater during a preliminary test of seaworthiness) and the ranking military leader who observed the aborted test. Signing off on the launch, the ranking officer lamented the absence of the King, apparently the only person with authority to cancel the launch.

This story lends itself to talking about the dangers of rigid hierarchies, and I'll probably return to it at some point, rigid hierarchies having sunk more than a few ships in healthcare. But the Vasa also illustrates principles about the hierarchy of error and harm prevention:

1. Eliminate or prevent mistakes. A better design would have prevented the Vasa from going down.

2. Make mistakes that have been set in motion visible. The ship did not perform as expected when subjected to simulated sea-like conditions. Not launching a ship with dubious stability would have prevented the Vasa from going down.

3. Mitigating the hazard should a mistake occur. Lifeboats prevented some people on the sinking ship from going down.

4. Education/re-education about how to manage known hazards. Swimming lessons might have helped some people save themselves.

Healthcare has been criticized for the tendency to bottom feed when it comes to risk reduction, meaning that we tend to rely on risk-reduction strategies low on the hierarchy. This doesn't mean that, as individuals, healthcare professionals don't care about risk or don't want things to turn out well. It simply means that we're more likely to select and implement interventions like "review policy" with individuals who make errors than to examine the underlying factors that allowed frontline workers to err. We spend a lot of energy attempting to teach front line clinicians how to save themselves.

So if we got out of the lifeboats and headed north on the risk-reduction hierarchy, how far could we go and what would the consequences be?

Health and healing are complex, and it's fair to say that we're sailing more than a few badly designed ships. 1 in 7 Americas lack healthcare insurance. Healthcare disparities are rampant. Patients are older, sicker, and rounder than they used to be. Our system does not incentivize prevention. A better design would avert many crises. But redesign of healthcare--something that appears to be emerging as a national priority--is outside the locus of control of individual clinicians, irrespective of how often or how nobly we face the consequences of the current bad design.

So how can front line clinicians prevent a poorly designed vessel from sinking? One answer is: embrace processes and procedures that make mistakes set in motion visible. Be able to identify emerging practice changes as the higher-level risk-reduction strategies they are. Get ready to cancel the launch!

A bar-code scan reveals a mismatch between ordered medications and a similarly packaged one in the patient’s drawer: you’ve cancelled a launch. A pre-procedure time-out reveals a site-of-surgery discrepancy: you’ve cancelled a launch. Reading back and verifying a telephone order (insulin 50, five-zero, units sub-cutaneously now) reveals the prescriber on the crackly line said one-five (15), not 50 units of insulin: you’ve cancelled a launch.

Cancelling a launch is not as good as preventing mistakes from occurring. But this approach trumps lifeboats and swimming lessons. Right now, healthcare is adopting, occasionally adapting, risk-reduction strategies from other industries, industries more reliable than ours.

The best risk-reduction strategies, in my opinion, are yet to come. As healthcare workers--bright, caring, and competent individuals—come to understand the principles that drive reliable performance, participate in developing highly-reliable processes, demand these be vigorously applied, and eventually come-of-age in an environment where reliability is the norm, it will no longer be necessary to report preventable adverse health events as aggregate data!

See you there!

Sign, sign, everywhere a sign.

I keep getting, ummm, signs.

A sign that arrived in an e-mailed joke a few weeks back inspired me to write about high reliability.

Then Bill ("Here's Your Sign") Engvall gave me one, causing me to make mention of the fact that all risk-reduction strategies are not created equal.

And just a few minutes ago, I found this one while checking out the Facebook page of Shelby Caldwell, a talented young photographer:

used with permission

I'm not certain if the abundance of signs means the people at this grocery store really, really, really don't want you to fall (in which case a bag boy with a shovel and some salt might confer better protection) or if they want to warn you that you're about to fall irrespective of which space you park in or which cart queue you pull from.

(It may be helpful to know that where I live snow, especially spring snow, often melts before a "snow removal crew"--ummm, bag boy and shovel--can be mobilized.)

Since I can't say it better than the 5 Man Electrical Band did many years ago, I'll leave you with this:

"Sign, sign, everywhere a sign
Blockin' out the scenery,
breakin' my mind
Do this, don't do that, can't you read the sign"

"Here's Your Sign" is not a High-End Risk-Reduction Strategy. Go Figure.

I live in the southern part of the U.S., and, like most of my friends, I like Bill Engvall, one of the funny men on the Blue Collar Comedy tour. Larry the Cable Guy, not so much, but I really think Bill Engvall is funny. If you don't know who he is, here's one of Engvall's jokes (and a link that takes you to the lyrical version of "Here's Your Sign"):

A couple of months ago I went fishing with a buddy of mine, and as we pulled his boat into the dock, I lifted up this big 'ole stringer of bass.

This idiot on the dock goes, "Hey, y'all catch all them fish?"

"Nope. Talked 'em into giving up."

I like Bill Engvall’s take on the human condition. It helps me make it through the Walmart. But when I go to work, I try to leave Bill behind. Here’s why:

In Chipping Away at Risk, I talked about how professional standards in other industries call for the use of the highest feasible strategies to manage predictable risks, and noted that similar thought processes are not yet considered "the norm" in the healthcare culture. In healthcare, it’s easy to draw from our duty-oriented traditions, falling back on what an “A player” wants to do on a good day rather than what a “B player” produces on an average day. (We will not discuss "C players" today.) But Human Factors research tells us that different, more reliable processes are needed to manage predictable risks that arise when people, processes, and equipment converge: "Hey, y'all catch all them fish?"

So here’s a user-friendly list of risk reduction strategies, one that’s widely used by the safety analysts at the Institute for Safe Medication Practices. The strongest error-reduction strategies are listed first, with the less effective options lower on the list:

• Fail-safes & Constraints
• Forcing functions
• Automation & Computerization
• Standardization
• Redundancies
• Reminders & Checklists
• Rules & Policies
• Education & Information
• Suggestions to be more careful or vigilant

And three examples showing how these principles look “on the job”:

1. A patient care unit where the primary fall-prevention intervention involves nursing personnel “keeping a close eye on patients at-risk to fall ” is using a less reliable fall-reduction plan than a unit where nursing vigilance is augmented by standard measures (such as the opportunity to use the bathroom every two hours). This can be predicted because scheduled opportunities to use the bathroom standardizes an intervention while “keep a close eye on them” relies on personal vigilance, a much weaker risk-reduction strategy.
2. A neonatal unit that has a policy stating only 10 units/mL heparin will be stocked in the unit’s automated dispensing cabinet (ADC) has a less reliable risk-reduction plan in place than a neonatal unit where heparin products undergo bar-code scanning prior to delivery to the unit and prior to being prepared for a given patient. Bar-coding is an automated risk-reduction strategy with reliability that trumps both policy statements and the accuracy of humans when “reading the label.”
3. Port-free epidural tubing, especially those with distinguishing colors and features, makes patients safer than using standard IV tubing because the absence of a port is a constraint that can prevent inadvertent administration of parenteral drugs to the patient’s CNS, a tragic occurence that regularly happens when well-educated clinicians become distracted.

I hope the rank order of risk reduction strategies and the clinical examples give you something useful to consider about mitigating on-the-job risks and how to respond when an error occurs.

Stay safe, find some time to fish, and come back soon!

Where's Waldo? Finding Reliability in Surprising Places

Last Friday, I talked about look-alike, sound-alike (LASA) drug names, throwing out for discussion just one of the system-level risk points that predispose people to err. Remember Waldo, the popular figure in the striped shirt kids have fun trying to find? I think of risk points as "Waldos" because they're often significant stumbling blocks, features hidden in plain sight that undermine the ability to deliver intended care. Without specific measures that make Waldos visible in healthcare, they frequently derail our good intentions.

(Oh, and if I’ve sparked your interest in LASA-related drug errors, you can click here to access a graphics-rich, user-friendly, CE-granting tutorial about this problem. It offers a more complete discussion of LASA problems and prevention strategies. Disclosure alert: I'm a co-author of the piece, but I don’t receive any tangible benefit by sending you over to Medscape to access it.)

But today, I want to circle back to common beliefs about intention and individual performance, making comment about what's known about reliable performance.

If you're like me, you probably get a chuckle when signs like these hit your electronic in-box.

(The "Darwin Awards" are another funny cousin in this family of pass-along e-mails.) These "just do it" calls-to-action are helpful for instilling personal accountability when performance is not overly dependent on a system, like it is with, say, teenagers and curfews.

But imagine you are boarding a commerical airliner, and you see a warning posted in the cockpit that says, "This machine has no brains. Use your own." Are you staying on-board? It probably doesn't matter, because the crew isn't likely to!

The experience and competencies your flight crew and air traffic controllers bring to work are not considered sufficient to get a plane off of the ground if the plane's brains (think: radar, auto-pilot, computer) are on the blink. I know this from experience. Last year, I flew between Atlanta and Philadelphia weekly, a routine that was largely uneventful. But I vividly recall one flight that required a return to the gate, de-planing, and re-loading onto another aircraft, events that transpired when the captain nixed take-off because the mechanics could not explain to his satisfaction why a control panel light was behaving in an atypical fashion.

Aviation professionals understand that safety is a function of reliability, a term Wikipedia helpfully explains as the ability to deliver stable, predictable results under ordinary circumstances as well as when hostile or unexpected events arise. Aviation is highly procedure-oriented, and it's likely that the ability of individuals to perform in extraordinary circumstances, like when a plane lands on the Hudson, lies in the strength of the systems that support routine function. The aviation industry routinely adopts tools and technologies that enhance the considerable abilities of individuals to perform in a reliable fashion, and they share "Waldos" across the industry whenever the safety-threatening striped shirts are identified.

Human beings, healthcare's most significant output, are far more complex than airplanes. But this fact should not dissuade us from adapting reliability-promoting processes used elsewhere. Deviation from a standard flight plan (or plan of care) for cause--that is, for reasons that enhance benefit to individual flyers (or patients)--make sense only when deviation is not the norm.

I hope you'll stay safe, come back soon, and fly only in friendly skies!

The Problem with System Problems

You may have heard of Jennifer Thompson-Cannino and Ronald Cotton, authors of a recently published memoir "Picking Cotton," an accounting of Thompson-Cannino's mistaken identification of Cotton as her rapist and what happened in the aftermath of the tragic error. (Cotton served 11 years in prison before being exonerated by DNA evidence, an event that triggered Thompson-Cannino to experience near-stiffing guilt for her role in his conviction.) I've seen Jennifer and Ronald on 60 Minutes and caught them on several radio interviews, most movingly in a piece recorded for NPR's This I Believe series. (http://www.npr.org/templates/story/story.php?storyId=101469307).

They're sharing their story, a powerful testimony of love, forgiveness, and redemption. Jennifer and Ronald also champion a cause both hold dear: judicial reform, specifically the processes used to gather and present eyewitness testimony.

Thompson-Cannino and Cotton's journey is particularly remarkable because they have undertaken it together. When an accuser apologizes and a victim forgives, each experiences grace that only the other can offer. We are infrequently given a glimpse of healing like this, healing that comes from such a deeply personal place. But what may be easy to lose in the story of their personal triumphs is the role that system deficits played in the tragedy that befell them.

The problem with "system problems," I think, is that they often beg individual accountability, leaving us with the sensation of a debilitating ethical itch that simply cannot be scratched. Expressions like, "Lead, follow, or get out of the way," and "If not you, who? If not now, when?" suggest a general belief that things are under control, or can be brought under control. It's a matter of personal responsibility. Take me to your leader! If good people bring the good times, surely bad people must bring the bad.

So it's particularly interesting to me that Thompson-Cannino and Cotton, two people whose capacity for introspection and personal accountability are remarkably deep, are talking about system problems, looking past "the people" to focus on "the processes."

An analysis of events in the Cotton case reveals that the circumstances that led to Thompson-Cannino's initial identification of the perpetrator predisposed her to identify the most likely attacker, not the attacker. Cues and clues, erroneously, but not maliciously, offered by investigating officers further reinforced Jennifer's perception that she was right. The 60 Minutes piece was told, in part, by another person affected by this tragedy: the detective who investigated the case. A professional who, using the standard operating procedures employed at the time, helped to send an innocent man to prison for 11 years. If you're feeling the beginnings of an ethical itch, it may or may not be helpful to know that more than 75% of individuals convicted of crimes, then later exonerated because of DNA evidence, were convicted with eyewitness testimony that turned out to be erroneous.

DNA now offers us access to highly reliable evidence about what happened to who, under what circumstances, and where. When it's available, DNA evidence can corroborate or refute eyewitness testimony, making the likelihood of uncovering an objective truth far greater than it ever has been. Even without DNA evidence, the procedures used to identify perpetrators and preserve, but not influence, the memories of victims are now evidenced-based and should look different today than they did 25 years ago.

I think it would be fair, a word I use with great caution given what happened to Ronald Cotton, to say that it was not wrong to have used 'standard operating procedure' 25 years ago. But it would be wrong to use 25-year-old standard operating procedures today. It would be wrong to continue to do things in an unreliable way when someone's liberty or someone's life is at stake.

System level analysis offers a way to improve reliability in judicial processes, in aviation, in healthcare. It gives people who are very close to the action--like patients and clinicians--tools to see that everything may not be exactly as it appears on the surface.

That's what we're going to tease apart and talk about here at Florence dot com! I hope you'll come back again. Because it is not wrong to have used standard operating procedure 25 years ago, but it is wrong to use 25-year-old standard operating procedures today.

Next time: This picture paints a thousand words. (But I'm only going to use 500.)

Welcome to Florence dot com

I find inspiration, and occasionally wisdom, in unexpected places, and I hope you'll find some here at Florence dot com, a place for people interested in improving healthcare.

A few months ago, I happened upon a documentary about a senior citizens chorus from Northampton, Mass called Young@Heart. In it, an octogenarian suffering from congestive heart failure sings a rendition of "Fix You," a Coldplay song about learning from mistakes and fixing broken things, which drew critical acclaim for the chorus (plus hundreds of thousands of hits on YouTube and other sites that linked the clip in the fall of last year).

Even if you haven't seen Young@Heart or a clip of "Fix You," I'm certain you know someone like Fred Knittle. He's been in your ER, on your inpatient census, or on your patient roster. And you probably saw him at the Walmart a time or two. To me, Fred Knittle's rendition of "Fix You" says more about healing--and the valor of persevering--than anything I've bumped up against in a very long time. The message hits home, maybe, because Knittle is backed up by his portable oxygen tank as well as his loyal choral compatriots. Or the meaning intensifies because Knittle sings his part and the part of his partner, a fellow chorus member who passed away just days before the piece was filmed. Or maybe it's because Knittle's remarkable baritone croon may not have anything to do with fixing at all.

The thing that I most love about the success Knittle enjoyed is simply that it came at all (he died on New Year's Day in '09). Knittle, if his cheerful optimism and wry accounting is predictive, lived a good life. His obituary shared events and accomplishments that evidence a life well lived: a devoted wife, children and grandchildren, military service, a long career in service to others, a loving, connected community. But it wasn't until Knittle's final years, most probably after receiving a terminal diagnosis, that he returned to a community singing group he loved and produced work that is making people around the world pause for a moment and think, really think, about what it means to care, to heal, to try, and to die.

Renewal coming from a broken place speaks to me. In the healthcare industry, we frequently produce an outcome we did not set out to achieve, making our work, from an engineering perspective, well-intended, but not reliable: in the US medical errors are the 8th leading cause of death. Each year, more people die as a result of medical error than die of AIDS or breast cancer. We are broken.

What ails healthcare is not a "one person" or "one profession" problem nor will the fixes be singular. Healthcare professionals, like the Young@Heart chorus, may appear too old, too tired, too exasperated, or too out-of-breath to always look like credible sources of hope. Fred Knittle didn't look the part either. While most performance problems in healthcare are rooted in our systems, that is, how we do business, solutions ultimately rely on what people come to view as important and how we adapt. I hope you'll return regularly to Florence dot com for cues, clues, and commentary about cutting edge trends in patient safety and that you'll find this a good place to share your insight and experience, whether you're a professional, a consumer, or both.

"Lights will guide you home and ignite your bones, and I will try, and fix you." Thank you, Mr. Knittle.