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It’s My Pool, It’s Your Pool

One of the more stressful events in my life is instructing a surgical resident on how to perform a complex operation.  Almost exactly the same stress level as instructing a student pilot on how to fly an airplane and carry out complex tasks such as cross wind landings and wing stalls.  Precision of communication in both is essential for safe outcomes.  But even more than Ip and studentcommunication is something aviators call “positive control” which is a simple concept:  it is always someone’s airplane – it’s mine, or yours, but never is there a moment that one of the two pilots, instructor or student, doesn’t have his/her hands and feet on the controls of the aircraft.  Flight training involves a lot of demonstrating of maneuvers by the instructor and then practicing by the student.  With all this back and forth, the obvious issue is that the airplane must ALWAYS be under the positive and acknowledged control of somebody in the first row.  The communication that is used in flight training is, “OK it’s my plane” or “now it’s your plane” and after that is acknowledged and the flying pilot observes that the non-flying pilot has control, the exchange is made.  This concept of positive control is another central pillar of the high reliability mindset.

 

We can easily apply this concept of positive control to everyday life since, as we have seen in previous blog posts, the high reliability mindset applies to all aspects of human performance.  I have made the point before; there is nothing uniquely specific that is “pilot error”, or “medical error” it is all “human error”.  The high reliability mindset is designed to combat human error in all aspects of human performance.    So, let’s use as our everyday example of the high reliability mindset the safety of children around a swimming pool.  My wife and I have always lived in the south and with all the warm weather we have always had a swimming pool in the back yard.  Sure we had fences around poolthe pool and all the usual safety devices that made us a little more comfortable, and so did everybody else.  But never a week went by that you didn’t read in the local paper about a tragic incident of finding a child in a swimming pool who couldn’t be revived.

The Centers for Disease Control publishes yearly statistics on these incidents.  Last year, there were 3,443 fatal drownings (non-boating related) in the United States, averaging ten deaths per day.  Fatal drowning is the second leading cause of injury related death in children ages 1 to 14 years (a third of people who die from drowning are kids) and children ages 1 to 4 have the highest drowning rates.  Sadly among children 1 to 4 years old who died from a preventable cause, 30% died from drowning.   These tragedies are preventable because they are another example of failure to use the high reliability mind set and loss of positive control – positive control of a swimming pool.

I gave my wife a few flying lessons for a while after we married and was always hammering the concept of positive control, that “it’s my plane” and now it’s your plane”.  We eventually gave up on that project but my wife never forgot the concept of positive control and it worked its way into our family culture and vocabulary.    As our kids grew up and spent more time in and around our own pool, we were both terrified of these potential dangers that went along with all the fun.  My wife and I always looked each other in the eye and exchanged those crucial words – “it’s my pool” or “it’s your pool”.  There was NEVER a moment when we didn’t know whose eyes were on the children around the pool.  There was NEVER even a second that we walked away from the pool without knowing and acknowledging positive control of the swimming pool by the other parent.   There was NEVER a moment when someone wasn’t flying the plane and fortunately we never even came close to having an incident with our own children or anyone else’s.

This concept is another crucial concept for patient safety in healthcare.   Joint Commission statistics indicate that among the most critical time periods for patients to suffer a serious and sometimes fatal error is during hand-offs of care from one provider to another.  Patients are three and a half times more vulnerable to error during and after handoffs – with loss of positive control – than during the course of the day.  This is especially important in large teaching hospitals where resident work hours are limited and multiple hand-offs occur over the course of the day and night shifts.  Another particularly risky time is during transport of a patient from one care area to another.  During these critical phases of recovery, patients are set up for potential disaster since they are actually under no-one’s care – there is actually nobody flying the plane.

Application of the principles of the high reliability mindset for safe outcomes in our patients is essential.  Patients must always be under the acknowledged (specifically communicated) positive control of a physician and/or nurse.  Lab data or checks of vital signs of post-operative patients needs to be communicated from one care giver to the next – guided by a written checklist – when care is turned over or transfers from one area of the hospital to another occur.  There can NEVER be a moment when nobody is flying the plane or watching the pool – that’s when critical information “falls through the cracks” and patients suffer complications that could and should have been avoided.

 

 

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Posted in High Reliability Mindset, High Reliability Organizations, Human Factors.

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2 Responses

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  1. skulljockey says

    Great analogy. As important as checklist lists are as an “aide memoire”, context matters. So often we look to simple tools , such as hurried checklists to reassure us that all is well. Medical error is human error. The lens of communication whether verbal or through body language is the context . The tool huddled in context , keeps our patients safe.

  2. Bette says

    Thank you for the good writeup. It in fact was
    a amusement account it. Look advanced to more
    added agreeable from you! By the way, how could
    we communicate?



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