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Hic Sunt Dracones

My son likes to collect maps made by ancient mariners before they had discovered much of the world.   In the sepia tones of antique artists, the world know to them is drawn as best they could and where the land ends and the seas end, there are a bunch of squiggly lines labeled “Hic Sunt Dracones”. I had to figure this one out but it seems to mean, “here, there be dragons”.  To the ancient mariners there was nothing known about the end of their world and nothing good, only unknown and certainly painful disasters that could be had by trying to go there.

here be dragonsThis was the “terra incognito” – unknown land – of the ancient people. But even in our world today there are lands where dragons still live, these are places where all kinds of unknowns, unaccounted for things – our very own dragons – lurk awaiting an opportunity for us to let our guard down to strike.  The difference between ancient times and our modern world is that we go to the lands of “Hic Sunt Dracones” all the time.  We expose ourselves and our patients to these multiple risks of being devoured by dragons not out of ignorance and certainly not out of malice but simply by not realizing we have trespassed here in the land of “Hic Sunt Dracones”. If we unknowingly enter the land of dragons then it is not possible to have made plans to deal with these risks and we have exponentially increased those risks.  It is the hidden risks, the unaccounted for and unplanned for circumstances that the high reliability mindset teaches us to avoid at best but certainly to anticipate and plan for the possibility of happening upon a dragon if we stray into their midst so as not be caught completely unarmed.  The more time we spend in the lands of “H.S.D.” the greater risks we accept.

Thus a critical skill and integral part of the high reliability mindset is to be able to account for everything that is known, to script as much as can be scripted and plan for times when unknown and unseen dragons might appear.  “Johari’s window” of information theory (there is actually nobody Johari's windownamed “Johari” the name derives from the developers, psychologists Joseph Luft and Harry Ingham, who in the late 1950’s constructed the model and combined their first names for the label) is an excellent conceptual model for practitioners of the high reliability mindset. The model has four categories defined by information that is known to you, known to your team members, unknown to you and unknown to your team members.

Dragons lurk in the “unknown” box waiting for an opportunity to inflict their special brand of harm on us, our patients and our plans.  High reliability practitioners shift as much information into the “open information” box as possible by asking probing and sincere questions and encouraging honest and complete input from all team members which eliminates “blind” and “hidden” information.  The value of knowing where the dragons live offers users of the high reliability mindset and their team members as much time and “mental bandwidth” to deal with unknown dragons.  This requires shifting tasks and prioritizing steps of a procedure to less time intensive portions of procedure so there will be more time to manage the dragons that will appear and prevent these surprises from turning into disasters.     This is an especially relevant skill for high reliably mindset adopters with the emphasis on, and influence of, the ‘soft’ skills of leadership behaviors such as cooperation, inter-group development and interpersonal communication skills as well as team building and maintenance.

Consider all the places where dragons lurk such as in operating rooms, with our patients who have unknown lab values, unaccounted for diseases, or are taking unknown medications.  Recently, I spoke with a fellow surgeon who had a patient suffer major bleeding complications after elective surgery.  He had carefully stopped the patient’s coumadin a week in advance, made sure she understood the instructions, and discussed it with her family that the patient was to take no coumadin, not even an aspirin.  When the surgeon was giving the family an update, while she was still having dangerous hemorrhage, he again asked the family if they were sure she had stopped the coumadin. They were absolutely positive – the only medication she was still taking was her warfarin. Ouch, a dragon bite for sure, the high reliability mindset would demand a repeat prothrombin time the morning of surgery – to make sure to find the hidden dragon.


Know which dragons inhabit your world and know where these dragons live, know where other dragons are likely to hide and know where, even if the chances are small, that still other dragons might be lurking in spite of all these efforts.  Practice and perfect the skill of knowing that there is at least one other critical piece of information that you don’t know and play the high reliability “what if” game to bring into the open Johari window all the vague possible dragon appearances and how you and your team will fight them.   Make sure everyone on your team knows everything you know and that you know everything they know – then discuss what you will all do when the dragon rears his ugly head. Move as many tasks to open times when there is the leisure to deal with them so you have the time and mental acuity to handle the dragon fire or you will get scorched.


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Posted in High Reliability Mindset, Joharis Window, Patient Safety.

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  1. Jenibelle says

    Your story was really ifnomrative, thanks!

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