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It All Comes Down to the Last Slice of Cheese

cheeseFor the two or so years I have been writing this blog on the topics of human error and the High Reliability Mindset, I’ve had the pleasure of a lot of interesting discussions with some very bright people who share a passion for patient safety.  Recently, I’ve had a few really good talks with a friend in Canada and another in Ecuador who have adopted the principles I have outlined.  They wanted to discuss in more detail some thoughts on the role of individual performance within very complex systems that have multiple moving pieces.  How might adoption of our HRM principles defend against all the sources of error in other parts of the system where we, as mere individuals, have little control and even less influence?

The High Reliability Mindset is all about optimizing individual performance within the complex system of healthcare delivery using lessons imported from aviation safety.  These principles can be effectively exported to our medical practice as well as most of our daily activities.  The individual is crucial in the chain of events leading up to disasters.  Just read any issue of the Proceedings of the National Transportation Safety Board and it is clear from virtually all of their investigative conclusions that the individual has the ultimate and final role in the prevention of an accident, even when multiple system factors have conspired against us.  Even more sobering is that often individual error that is cited as the primary cause of the accident itself.  The individual is that last slice of Swiss cheese in Jim Reason’s famous model of error in complex systems.  Reason’s model postulates multiple levels of protection from possible error exist within the system ranging from organization, supervisory and pre-conditions for error that represent “shields” against adverse occurrences.  The holes represent weaknesses in these defensive barriers at each level.  Weaknesses in any of these “shields” represent either failures of the broad system to catch potential error or actual fostering of error by setting up pre-conditions where error is likely to occur.  By definition, any error that falls through holes in the system to the final level of the individual represents a failure of the system.  So, the final shield from error in this model is us, the individual, who represents the last opportunity to catch and prevent a system based error.  This is a principle broadly known as “error trapping” – catching those small missteps before they have a chance to grow into major disasters.

This is why the last barrier, individual performance, is so critically important since it represents two critical issues in patient safety.  Not only is the individual the last chance to catch system errors, we also can be a possible source of errors when there is a breakdown in individual performance.  Any event that originates with us at the individual level results from a cognitive or decision making error.  We are in a unique position in the error chain of events in that we are the only member of the team with no additional safety barrier beyond us to check our actions and catch a potential mistake that originates here with us.  It is important to emphasize this point; there are no additional barriers to catch our own errors.  That is precisely the role of our HRM training.  Enhancing the error free performance of the individual with High Reliability Mindset training is one of the most important ways to close the holes in our own cheese and strengthen the last safety barrier between risk and disaster.

aristotleTherefore the High Reliability Mindset can be thought of as a 5th slice of cheese and perhaps the most important slice when we combine Reason’s theories with those I have proposed here.  So, often times it just comes down to our individual expertise, to recognize and trap system errors as they work their way through the holes in the other barriers and to be sure we utilize our High Reliability Mindset tools to prevent us from being the source of an error with no further safety net.  As Aristotle (384-322 BC) said, “Excellence is an art won by training and habituation.  We are what we repeatedly do.  Excellence, then, is not an act but a habit.”  Make the High Reliability Mindset tools your mark of professionalism and habit.  Excellence will follow close behind.



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

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  1. skulljockey says

    Another great blog. I am not certain that I agree with your statement that all individual errors are due to cognitive or decision making errors. We have come to realize in the medical community,that with time , there is significant decay of general and specific knowledge needed to perform consistently at a high level. Although recertification processes have address the knowledge gaps…. the process is not as robust as the process for pilots as an example ,who as they advance professionally and change aircraft, upgrade their performance ( which I define as competency in the work place rather than the simulator or classroom. )

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