Using ’Big-Deal Events’ to Help Us Learn

Patient Safety Quality Monthly

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February 12, 2009

Moving your organization from simply reacting to errors to proactively preventing errors is a key part of building a strong culture of safety. To prevent problems, we need to know about them and be able to openly discuss and learn from them. In healthcare, we are sometimes reluctant to make a big deal about events because we don't want to scare our patients or perhaps open the organization up to questions—this makes it difficult to be a learning organization. This is unfortunate because people learn from big-deal events because they reach us at our emotional core.

The water landing last month of US Airways Flight 1549, provides a great opportunity to use a big-deal event from another industry as a safety moment to discuss and learn within our own facilities. Have you taken advantage of Flight 1549 to open conversations within your senior leadership or department meetings? Don't miss this opportunity.

Think how powerful it could be to have your CEO compare Flight 1549 to your organization and use it to ask questions that can advance learning.

The following are some of the key learning points I took away, which might make great safety moments or discussion starters within your leadership and department meetings:

• The vital importance of training: It certainly looks like the crew did just what we would have wanted if we were passengers on that flight. They all had the right competencies, were up to date in their skills, and did not hesitate to spring into action.
  • Discussion point: When we think about our competencies, whether clinical or nonclinical, do we look at them as vitally important things that may save a life, or just a check-off box? Are there things that would keep us from springing into action?
• The rapid response of the community. Within minutes, the ferries on the river had gone from their normal activities into rescue mode. The news media asked one of the ferry crew members, "What were you thinking about?" The individual responded, "We train for this all the time. I wasn't really thinking, we just did what we had practiced."
  • Discussion point: Comparing the response of the river community to our facility emergency preparedness plan, have members of our community drilled with our organization enough so they could respond as quickly and effectively?
• Clear division of labor in an emergency. The crew had only about three minutes to perform actions in a difficult and highly emotionally charged situation. The cockpit and cabin crews appear to have performed admirably—they all knew what to do and how to do it.
  • Discussion point: What can we learn from this about the ways we manage our CODE responses or our rapid response teams?
• Importance of learning from near misses. Although no one was killed, this was a real big-deal crash. Yes, there were a lot of well-trained people and right behaviors, but there was also some good luck as well. Does the fact that no one was killed make it any less important to the airlines or the National Transportation Safety Board or even to us—the flying public? It shouldn't.
  • Discussion point: Do we honor near misses? When we have events where we are fortunate to have good luck, do we treat them as though we didn't have good luck? Even if the worst doesn't happen, we should learn from events as though the worst did happen. What is a recent example in our facility in which something could have gone very wrong but didn't because of luck? Did we analyze that event based on the worst case? Why not?

Talking about big-deal events is a great way to open up conversations that get to the shared values and beliefs that make up our culture of safety. It is a good habit to spend a couple of minutes at the beginning of your leadership or staff meetings on a safety moment. Maybe using Flight 1549 can help build that habit.

Ken Rohde
Consultant
The Greeley Company

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