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Imagine Patient Safety: A preview of Life’s Coming Attractions

Of all the wondrous and almost imponderable capabilities of our marvelously advanced brain, the most spectacular is our imagination.  The creative power of imagination occupies the central role in the achievement of success in every field.  Imagination is the driving force behind the advancement of humans from knuckle dragging cave dwellers to space travelers and web surfers.  If our far-ago ancestors had not imagined a better way to kill saber tooth tigers or grow food, and then tried those ideas out, we wouldn’t be here.  Imagination is a power beyond just creative visualization, it is the ability to form a mental image of something that is not there, not yet happened, and not yet experienced by our senses.  It is the ability of our brains to construct novel mental scenes, objects, or events that do not exist, are not present, and have not happened in the past.  Almost everyone possesses some imaginative capabilities, from daydreaming children at “pretend play” to generals scheming war games and nuclear physicists putting the pieces of the universe in order.  In some it may be highly developed; in others it may be weaker but imagination is a critically important component of our very intelligence.  There are some unfortunate individuals who lack the capacity of imagination and abstract reason that manifests itself as totally debilitating psychiatric illnesses such as schizophrenia.

To everything we apply it, the central function of our imagination is to free us from the bonds and restraints of the accepted world and open a world of infinite possibilities.  Many great scientists originate their theories first from their imagination.  Einstein, for example, was able to imagine alternatives to the sacred age-old Newtonian doctrine of absolute time, and discovered that time is actually relative to our state of motion.  And thus, from Einstein’s unlimited imagination, the theory of relativity was born.  There must have been hundreds of scientists who had come close to Einstein’s insight but lacked the imagination to see it because they were bound by the accepted dogma that time is absolute.  Their lack of imagination made it untenable to consider other possible theories.  Einstein captured it best when he said; “Imagination is everything.  It is a preview of life’s coming attractions.”  Preview is absolutely the perfect word – “to view before it actually happens”.  Our imagination makes it possible to (pre) view a whole world just in our mind’s eye.  Our imagination gives us the ability to (pre) view situations from different perspectives before anything actually occurs, and enables us to mentally relive alternate outcomes from the past scenarios and explore infinite possibilities for the future.

So as students and practitioners of the high reliability mindset might we be able to identify a lack of imagination as a risk to patient safety?  Consider one of America’s most gut wrenching tragedies, the loss of Apollo 1 and the death of our three mission astronauts, Gus Grissom, Ed White, and Roger Chafee.  The accident occurred during tests on the launching pad leading up to our first Moon mission that was scheduled for February 21, 1967.  Problems with the test arose almost immediately.  Grissom entered the spacecraft first and hooked up his oxygen supply.  Over his microphone he described a strange odor, and the crew stopped to check their spacesuit oxygen hoses.  After discussions between Grissom and mission control they decided to continue the test.  The next problem was a high oxygen flow indication that triggered the master alarm.  The three men discussed the issue with environmental control system personnel; the matter was not really resolved but the test continued.  A third serious problem arose in communications with mission control.  The crew made adjustments but still continued the test.  Abruptly instruments showed another surge in oxygen flow and seconds later, one of the astronauts, probably Chaffee, announced almost casually over the intercom: “Fire, I smell fire.”  Two seconds later, Astronaut White’s voice was more urgent, “Fire in the cockpit!”  Procedures for an emergency escape likely began but in practice sessions the crew had never accomplished the routines smoothly.  First, Grissom had to lower White’s headrest so that White could then reach above and behind his left shoulder to actuate a ratchet-type device that would release the first of a series of latches and eventually pop open the hatch.  It never happened.  Firemen arrived within minutes but tragically, it was all too late.  Still strapped into their seats, the three men were dead.

NASA appointed a review board headed by astronaut Frank Borman to carry out an inquiry into the causes of the disaster.  Their conclusion was, “in its devotion to the many difficult problems of space travel, the Apollo team failed to give adequate attention to certain mundane but equally vital matters of crew safety.”  What?! This wasn’t an answer; it was an indictment of NASA safety policies and procedures.  The Senate wouldn’t accept this either and held their own hearings calling Borman as a witness.  He testified on April 11, 1967 and in a moment of incredulous disbelief and sometimes hostile questioning; New Mexico Senator Clinton Anderson asked Borman, “How on earth could this have happened?  How could three men be killed, on the ground, in a simple test of a space capsule?”  At first, Borman seemed lost for words and didn’t answer.  After a few moments of thought he said, “Senator, it was a failure of imagination.  No one ever imagined this; we just didn’t think that such a thing could ever happen so we never planned for it.”

The applications of lessons learned from this tragedy relate directly to all high reliability organizations as well as those of us in healthcare who promote patient safety.  High performance training is characterized by an incessant preoccupation with the possibility of failure.  The likely occurrence of errors and failures are the driving forces for enhancing team training, team function and system safety.  HROs manage risks by being completely consumed with understanding, anticipating, and imagining all possible chances for errors which give them the ability to plan for even small missteps before major adverse events have a chance of taking place.  HRO system safety is engineered with the expectation that errors can and will occur and HROs train their team members to anticipate, recognize and recover from them.  HROs continually rehearse solutions to familiar scenarios of error and strive to imagine novel failures and then script solutions to these scenarios.  HROs safety aims to never be confronted by the “unimaginable” with no plan for a positive outcome.  Instead of isolating failures, high reliability teams generalize them and instead of making local repairs, they look for team and system solutions.

One of these critical system solutions is to “war game” every possible scenario of error and design plans to solve them.  We can do this in our practice: work your imagination into every pre-procedural brief and pre-op time out.  This is a critically important game, in my OR we call the “what ifs”.  Go around the room to your team mates and ask them to imagine a “worst case scenario” and then role play a solution.  Imagine with them “what if this” or “what if that” and what to do about it.  As practitioners of the high reliability mindset we understand, as did Einstein, that imagination is the coming attractions of life.  Optimum patient safety demands that we use our imagination to plan for, no to imagine, unlikely scenarios and unlikely problems along with solutions to them that will avoid tragic outcomes no matter what situations unexpectedly confront us.

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  1. Heidi Allespach says

    Your definition of that elusive, marvelous creature, “imagination,” made me think of another construct which can also ebb & flow but feels so good when it is present: Faith (“…events that do not exist, are not present & have not existed in the past…”). “By faith & not by sight,” in other words. Faith, like imagination, enables us to believe…and to dream…that anything is possible. Bondage to the stark, heavy, black & white limitations of earthly reality are broken by these bright colorful birds of faith & Imagination and they enable us to soar so high & so free. No ceilings, no limits. These shiny birds are so unfathomable to the logical mind, aren’t they?

    Perhaps man’s need to use things such as substances, food etc is an unconscious way to approximate the feeling one receives when centered in imagination (leaving this world, escaping, breaking the bonds of the dull monotony of reality)?

    What about Jung’s idea of a collective unconscious? Do you think there could be a “collective imagination”? Back in 1983, two teams of researchers came out with two separate theories about health behavioral change which have rocked the counseling world ever since. They are so similar & are often presented together as they complement one another like a hand and the softest lamb-skin glove. However, again, they were formulated in different parts of the country by different groups of people. Yet these disparate teams came up with almost exactly the same ideas. Of course, this phenomenon happens all the time in all areas: technology, healthcare/medicine, the arts. If we think of ourselves, at our most basic core level, as a grouping of atoms, electrons (“energy”), then couldn’t imagination be shared unconsciously…in kind of a seamless fashion vis-à-vis that energetic pathway, if you will? Quantum physics….

    Personal question: So, if one is relentlessly involved in war gaming for the greater good…trying to outrun & outthink all bad outcomes before they happen by predicting & expecting the worse…how are you then able to disengage from that perspective when not at work? It would seem to be a very different transition to make; however, how critically important that perspective is in order to ensure safety!

    I am truly blown away by your website & really look forward to reading more of your blogs. I had no idea you were so involved in such amazingly cool stuff!



    • kenstahl says

      Thanks for your thoughts Heidi you bring a clinical psychologist’s insight to the concept of the “High Reliability Mindset” that is invaluable. I would like to pick up on your thread about Jung’s “Collective Unconscious” but with the heads up that I’m not a psychologist I have only read the basic texts in my college psych class and medical school. I think Jung was onto something but missed the mark with his model of a collective or universal consciousness. In my opinion the universality within us is not so much in our consciousness but in the fact that we recognize there is an undisputable i.e. universal truth and unifying or collective correctness of many of the physical and even intellectual ideas about our world. For example it is not unusual for scientists in different countries who work on the same problem to come up with the same solution and it is well known that there are shared discoveries and even shared Nobel Prizes for research discoveries. Smart people will approach the same problem in a similar way and often come up with the same solutions because there is a correct answer to discover.

      This twist on Jung’s ideas tie in nicely with the theme of this blog, which is the universality of brain function itself and why safety lessons learned in high reliability environments such as the airline cockpit can be used in healthcare and patient safety. Although the vocabulary is different the mindset and solution algorithm is the same. It is because our brains are similarly wired to process information and problem-solve in similar ways and importantly, to be vulnerable to similar errors.

      So it is faith and religion, as you also comment, that has universal truths. Although different people in different countries have different names and ways to worship, there is an underlying universal consistency in the belief that, what ever we choose to call Him, there is a Higher Power greater than any of us. Religious leaders and believers can get along with each other so well as we may not so much share a “collective unconscious” as a collective answer to the presence of this higher power.

      This is starting to get beyond my knowledge base so other comments from readers of this blog and practitioners of The High Reliability Mindset please share your thoughts.

  2. Heidi Allespach says

    ….”In my opinion the universality within us is not so much in our consciousness but in the fact that we recognize there is an undisputable i.e. universal truth and unifying or collective correctness of many of the physical and even intellectual ideas about our world….”

    Agreed…but I like to think there is a little of both. While there are universal truths, how we GET there, that “recognition,” may be by the path of something we cannot actually describe with words nor operationalize/quantify. Perhaps this is the “art” in medicine…an intuition which, when honed, works like a sublime nose to “sniff out” the higher truths of universal correctness & order. Once we do get there, we are then able to quantify & control & create models of a higher order for patient safety and other domains. This intuitive self may be the “imagination,” or work within the imagination to help it to flow towards the discovery of those truths…and all may be part of that collective unconscious Jung theorized existed.

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