Reducing Risk

I was lucky enough to share a really good curry with four pilots and two air traffic controllers last weekend. As the evening wore on talk swung around to all things aeronautical, and with over a hundred years of flying experience between them it was fascinating to listen in. Between filthy tales of what goes on in foreign climes and how they wind each other up when bored (who knew there’s a pilot’s “chat” channel over the Atlantic?), they kept returning to the same topic – safety.

Flying is a safety critical industry, and there was no doubt these professionals kept it absolute front and centre of their goals. However, it was the way they went about it that interested me. Safety is an easy concept to grasp, but how do we achieve doing something inherently dangerous with as little risk as possible? Surgery is complicated, and mistakes happen, and we would do well to learn from each other.

Safety doesn’t just happen. It can’t be planned in from the start in a hugely complex activity like aviation. When the Wright brothers first took flight, they had little idea of the factors that might kill them. We learn from our mistakes, and alter how we do things in future. So how do we learn, and how do we change?

Making mistakes

Complicated activities lead to complicated mistakes. We must feel confident to re approach difficult problems. This requires a pragmatic attitude; surgery needs to be done- if the surgeon has done the required training, and gained the experience necessary then they are in a position to approach the problem, and yet things may still go wrong. Unforeseen problems rear their ugly heads at the most difficult times. Things happen but the surgeon must carry on operating on the next patient, and the one after. This requires some self-confidence; measuring one’s worth oneself rather than by the judgement of others. So the surgeon needs to make sure the way they value themselves is responsible and rational.

Feedback

When something goes wrong, the surgeon and their team need to admit to it, not to brush it under the carpet as “one of those things”. Just as the road traffic “accident” has been replaced by “collision” – every surgical “accident” has a cause and needs to be classifed as an “incident”. The surgeon, the team and their colleagues need to appraise the situation and work out what can be done better next time. Assigning fault and blame to an individual who is trained and experienced can be counter-productive. Will that team be as open if they face punishment?

Feedback requires us to swallow our pride, to realise that polishing our ego can only lead to dangerous mindset of infallability. Protecting the ego leads to a narcissistic attitude where mistakes are blamed on others, rather than on oneself (as with poor self-confidence)

Assuming a trained and experienced team, blaming individuals doesn’t work! We must look to faults in the system (if there is a system!) In complicated tasks the mental workload can be high. We can reduce this by systematising everything down into simple protocols. If the anaesthetist always keeps the drugs in the same place, calculates the amount required in the same manner, if the drugs are checked and counter checked on the same checklist then things should happen automatically, freeing up the concentration of the surgical team to watch for future problems.

If something goes wrong, we need to analyse the issue and produce a written checklist of what to do if it happens again, not freestyle a solution in the heat of the moment. These analyses and checklists need to be circulated to everyone involved, including outside then team, and revised and improved regularly.

In the case of problems that require solutions in seconds e.g. breathing difficulties, the team needs to commit the lists to memory; pilots call this “mouth music”. The checklist is recited, and actions performed and verbally confirmed. For breathing difficulties it may be “vapouriser off; check oxygen; confirm bag inflation ; circuit obstruction check ; prepare tracheostomy set ; start timer ; theatre nurse to call blood O2 levels every 15 seconds”. To do this properly requires rehearsal, both in simulation and in a live situation.

Resource management

The temptation to see surgeons, pilots or any other skilled team leader as an untouchable “sky god” or “theatre rock star” can give rise to poor dynamics, where other team members feel less able to feedback their observation- especially if these observations are critical. Again, ego needs to left to one side, and the ultimate goal of safe process prioritised.

Bringing it all together

Safety takes effort, systems and the right mindset. Any responsible professional who works in a safety critical industry needs to take care that as much effort is invested in minimising mistakes as in improving their own education.