Wednesday, April 8, 2009

What Dropping a Truck Bed Taught Me About Patient Safety

Four years ago an accident in my shop gave me a new perspective on errors and mistakes in health care. I have my son, a commercial pilot and A & P (airframe & power plant) certified mechanic, to thank for helping me find that different perspective, and making me curious about what we could learn from mechanics, pilots, and industrial safety engineers that could apply to health care. I’ve been learning ever since, and wishing I’d learned these concepts in medical school or residency!

The perfectly balanced steel truck bed crashed to the concrete floor because of my failure to follow our agreed upon plan that he outlined during the “time out” before undertaking the high risk maneuver. Then he said he wanted to take a picture of the mess to put on our website that chronicled the restoration process. Why? “To share our mistake, so that no one else tries the same thing, Dad. I guarantee you someone else will try the same thing. I don’t want them to get injured.”

Getting over my reluctance to share my mistake and the root causes of it with the world, I realized I should be less concerned about embarrassment, and more concerned about not wanting anyone else to be harmed. His training at Purdue taught him the key concepts of high reliability and safety. Karl Weick and Kathleen Sutcliffe’s excellent little book, Managing the Unexpected: Assuring High Performance in an Age of Complexity describes high reliability organizations as being “mindful” of how mistakes happen, and how to build in mechanisms to prevent catastrophes from happening. Another term they use is “preoccupation with failure” – understanding how small events or pieces of information often give us warning that a situation has the potential to deteriorate and cause great harm. Watching good pilots, mechanics, intensivists, hospitalists, surgeons, and other physicians in their daily work being preoccupied with failure is a positive attribute, if I’m a passenger or patient affected by their knowledge and decisions. It means that they know the signs of impending failure, and how to intervene to prevent it.

These concepts of high reliability, which come from engineering and cognitive psychology, may provide us a path to improving the reliability of health care. Health care organizations focused on primum non nocere (First Do No Harm) as their core business philosophy, and that have trained their staffs in the principles of high reliability, report better teamwork and operating results.

Sharing my shop mistake on the website was a great experience. I had no idea how many physicians, hospital executives, or their spouses were “gear heads” regularly checking on our progress with the old truck! The most common comment was, “I can’t believe you did that”, followed by, “I’d probably have done the same thing.” Then we laughed, learned, and moved on to another topic.


  1. I'm looking forward to your posts. In healthcare we are often too concerned with saving face and fearing litagation rather than sharing pitfalls and warning others about them. We should view "mistakes" more as a hole into which anyone could fall and warn others.

    After all, if there was a hole in the road, we would have the highway dept. section it off rather than being embarrassed that we just hit a pothole.

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