Knowledge exists but mistakes happen in almost any system or process that deals with complexity – in volume and knowledge.
Voulme and complexity of what we know exceeds the ability of an individual to execute, safely, reliably and consistently.
Oct 30 1935 Wright Airfield long range bomber trial - plane took off climbed to 300 ft stalled and crashed 2 of the 5 crew died. No mechanical error crash due to pilot error. Too many things – 4 engines for 1 pilot to deal with. Boeing lost the contract nearly went bankrupt, group of test pilots got together and created the first pilots checklist. Plane eventually went into service as the B-17 and the army ordered 13000.
Engineers talk about all or none processes – these are particularly susceptible to faulty memory and distraction. Going shopping for cake ingredients, flying a plane, evaluating a patient all examples.
2001 Critical care specialist at Johns Hopkins named Peter Pronovost decided to try a checklist for the 1 problem – central line infections. The checklist had 5 steps all well known. Asked nurses to observe Dr.s for a month, in 1/3 of cases at least 1 step was skipped. Got the checklist implemented and the 10 day line infection rate went form 11% to zero. Could scarely believe the results so monitored for a further 15 months. In the entire period there were 2 line infections. Estimated impact - prevention of 43 infections and 8 deaths and saved $2m in costs. Went on to apply to other processes such as pain management etc examples p38.
Prof Brenda Zimmerman and Prof Sholom Glouberman New York and Toronto Universities proposed 3 dfiferne kinds of problem, the simple the complicated and complex.
Building – knowledge and application of knowledge. Projects too big for the master builders of previous ages, complexity exceeds any individual competence.
Builders use a construction schedule (gant chart) and a submittal schedule this specifies communication tasks – gives a process for managing the unexpected and uncertain, makes sure a and b speak to each other and work out a solution. Individuals are fallible collaboration groups less so, particularly if they are good communicators. The major advance in construction in recent decades has been perfecting tracking and communicating. Biggest cause of serious error is failure of communication. Construction is somewhere which empowers people – authority moves to expertise.
Federal response to Katrina a good example of the opposite a command and control system where every decision had to be pushed up the chain. Quickly overwhelming the system. UPS a private company in contrast which has a culture of allowing drivers to solve the problem of delivery was back on track v quickly. Wal Mart similarly decentralised decision making within 48 hrs half of their 126 damaged stores were functioning. P77 for more detailed case study.
David Lee Roth Van Halen contract clause for bowel of M&M with all brown ones removed. Designed to check specs were being read and checked because the band were taking a huge production show to many places that had never dealt with the requirement.
Radio read back procedures – mechanism for ensuing understanding in critical situations. Waiters read back orders for the same reason!
Atal asked by the WHO to find an effective way of cutting down on post operative infections.
Critical requirements, SIMPLE, MEASURABLE ,TRANSMISSABLE
Cleared for take off check list for pre surgery, culture change as surgeon not allowed to start until given the green light by the theatre nurse.
Surgery has 4 big killers: Infection, bleeding, problems with anaesthesia and complications (the unexpected).
Initial attempts around surgical check lists too unwieldy. Back to the drawing board to learn what the airline industry does:
Must be a clear pause point at which the list is implemented.
Decide on design of a DO-CONFRIM list or a READ-DO list
Not too long 5-9 items
The checklist is quick and simple and designed to buttress the skills of expert professionals
Revised surgical checklist reviewed Jan 2009 in New England Journal of Medcine. Ultimately checklist improves surgical outcomes with no improvement in skill of the surgeon.
Learned occupations / professions define codes of conduct.
Common elements. Expectation of selflessness – the needs of others come first, expectation of skill, and expectation of trustworthiness. Airline industry adds a 4th – discipline to follow prudent procedures and work with others.
A culture of teamwork and discipline critical to making it work as a system