In 1979 Tom Wolfe wrote an epic story about the pilots engaged in our postwar, hugely risky experiments with high-speed rocket-powered aircraft. The history of these men’s triumphs over both physics and physiology lead to the selection of the first Project Mercury astronauts by NASA to start our space program. He called it “The Right Stuff” and as the name implies, these guys had it. Yet in one of his more attention grabbing lines Wolfe wrote, “There are no accidents and no fatal flaws in the machinery, there are only pilots with the wrong stuff”. WHAT? I thought you said these guys were the very embodiment of the right stuff – which is it Tom? The FAA and the National Transportation Safety Board would seem to agree with Wolfe. Even when the wings fall off an airplane the final cause in the accident investigation report usually reads something like, “The pilot failed to maintain proper control of the aircraft and adequate separation from the ground, a possible contributing factor was…oh yeah, the wings fell off”. The healthcare community would, in all likelihood, also agree. Those NTSB reports sound a lot like the Morbidity and Mortality conferences I sweated through for the years of my residency and fellowship. We called those conferences the “Thursday afternoon massacre” and the unfortunate surgical resident who happened to be closest to the patient when his “wings fell off” was shamed and blamed. The only ones who found humor in all of this were the medical students in the back row that got a good laugh at the expense of the poor guy squirming on the stage.
But the blame of the NTSB and surgical superiors and the ridicule of medical students points out an unresolved paradox and topic of debate among those who study high reliability theory. Is it the system and its machinery that causes fatal events or humans who operate that machinery within a complex system who commit unforced errors on their own? On one side of the argument are the Jim Reasons of the world with their interminable Swiss cheese diagrams that show a Rube Goldberg-esque interrelationship of error commission with fault spread out among everyone and everything involved. The other side of the argument is populated by Tom Wolfe, my former surgery department chairman, the NTSB and those who believe the individual practitioner simultaneously provides both the final opportunity to catch and prevent system errors from inflicting harm on patients AND an unprotected source of error that can fall directly on the patient leading to disaster.
The most detailed NTSB reports and the more honest root cause analyses of healthcare errors document that every accident, incident and near miss is the result of a long and complex chain of events that never happens if that chain is broken at any link. This trail is littered with a litany of “if I’d only’s” pointing out all the opportunities that presented themselves to have understood what was happening, intervened and prevented the ultimate, but certainly not inevitable, unfortunate outcome. Thus the inseparability of human performance from the system within which we operate. It is the system that is a common cause of risks of error but the human who must catch it and prevent it from occurring while at the same time avoiding any mistakes on their own.
This forms the very foundation of the high reliability mindset. The high reliability mindset teaches individual practitioners how to maximize their performance even when confronted with unexpected events or time compressed critical situations. It teaches how to plan and carry out procedures while anticipating distractions, disruptions and imponderables to assure safe outcomes. It teaches us how to maximize our team performance and team communications so that we don’t become the source of an error and we are able to catch all those coming down from above. In the end it might not be so much about the “right stuff” or the “wrong stuff”, but high reliability performance is more likely dependent on, as Lawrence Gonzalez says in his wonderful book, “Deep Survival”, “knowing your stuff”. Knowing that “stuff” forms the basis for high reliability mindset which I believe is the key to reducing errors in patient care, but what do you think?
Ken Stahl, May 3 2011Share on Facebook