Airlines and Operating Rooms: what can they teach us about safer Lockouts?
Airlines and surgical theatres have seen huge improvements in incident rates through understanding the human at the center of the challenge. The introduction of “challenge and response” checklists has saved thousands of lives per year and can provide a valuable lesson increating safer Lockouts.
To Err is Human
I recently read a harrowing story of a Nurse of 25 years, who sadly took her own life after making a fatal medical error.
Kim Hiatt was a nurse passionate about her patients. Having grown up in a family of clinicians she was dedicated to her work and helping others. She was not only competent Nurse, but she excelled in her role.
Her first medical mistake in 25 years would cost the life of a frail 9 month old baby. After having mistakenly administered 10 times the dose of calcium chloride, the guilt of the incident proved to much for Kim.
The painful truth is she was by no means alone. Mistakes in medicine are surprisingly common and not only. Human error today is the leading cause of injury and fatality in most workplaces. Error it seems is a dangerous element of human nature.
The aeronautic industry was perhaps the first to make this conclusion after decades of air crash investigations.
As the technology that kept planes in the air improved, the weak link in airline safety became pilot error. Once upon a time, 80% of accidents in the air were caused by mechanical failures and 20% due to pilot error, in the last fifty years or so those figures inverted.
So how can it be that even after years of rigorous training, expert professionals can still be prone to making such disastrous errors?
Errors of incompetence and Errors of Ineptitude
Atul Gawande MD is a global expert on human error, having studied safety in medicine for decades, his work and insights have revolutionized safety in healthcare.
In his book The Checklist Manifesto he identifies two types of human error; errors of ignorance and errors of incompetence.
For much of human history, the first type of error, those of ignorance, were the norm and were the consequence of lack of information and knowledge. However, thanks to technological advances in the last fifty years or so that trend has changed.
Errors of incompetence, which result from poorly applying our knowledge are today most common. Simply put there is more to know, more to manage and more to go wrong. We are all equally prone to these mistakes and training isn’t necessarily a solution.
So, if we are all at risk and training provides no hope of a solution, what can we do? Fortunately, the answer is rather simple.
Checklists: a simple solution to a human problem
Checklists were pioneered first by the airline industry over 80 years ago in attempt to reduce accidents caused by those errors of ineptitude that we had spoken about before.
They proved successful, providing a valuable brake to skip vital steps in pre-flight preparations. This success of checklists were the inspiration for Gawande’s book and when introduced into the medical context brought astonishing results. In the operating theatres, pre-surgical checklists reduced mortality rates by up to 60% and in general medical care have been able to reduce deaths to zero.
However, despite their effectiveness, there was, and still is considerable resistance on the part of surgeons and pilots to the use of checklists. The frustration felt by these professional at the seemingly demeaning process of following checklists show that we all tend to underestimate our propensity to make mistakes.
Checklists for Safer Lockouts
So what can we learn from Atul and the airline industry to make work safer for our staff?
Lockout procedures are currently one of the most high risk activities that staff undertake. This is despite strong best practice guidelines and well established procedures. So what is going wrong?
The leading cause of accidents in Lockout procedures is simple-human oversight in effect the checklists are in place but they’re not effective.
The reason is clear if you put yourself in the shoes of a highly trained industrial engineer. Noise and distractions, complicated assessments, maybe a late night yesterday, maybe a child’s birthday this evening, a rush to get home, you’re working alone, you’re ticking the boxes, you drop a sheet, you skip a step…
Current lockout processes add stress and cognitive load to the engineer and often lack a fundamental feature of a good checklist, supervision.
It highlights the importance of good checklist design. As Gawande points out “good checklists are precise, efficient and easy to use even in the most easy to use situations”.
In developing “smart lock” our intelligent checklist for Lockout procedures, we combined guidelines from NASA and Gawande in order to build checklist that will never fail.
To help you understand how you can improve Lockout processes, we are giving away the secret sauce to developing the perfect checklist.
12 steps to a perfect checklist
- Checklist responses should portray the desired status or value of the item being considered, not just “checked”.
- The use of hands and fingers to touch, or point to, appropriate controls, switches, and displays while conducting the checklist is recommended.
- A long checklist should be subdivided to smaller task-checklists or chunks and where possible automated.
- Sequencing of checklist items should follow the “geographical” organization of the items in the work environment and be performed in a logical flow.
- The most critical items on the task-checklist should be listed as close as possible to the beginning of the task-checklist.
- Critical checklist items that might need to be reset due to new information should be duplicated.
- The completion call of a task-checklist should be written as the last item on the checklist.
- Checklists should be designed in such a way that their execution will not be tightly coupled with other tasks.
- Every effort should be made to provide buffers for recovery from failure and a way to “take up the slack” if checklist completion does not keep pace with the external and internal activities.
- Staff should be aware that the checklist procedure is highly susceptible to production pressures and insulated from the pressure to rush.
- Checklists should be made as simple as possible, removing extraneous information and automating its checking features, reduces work for staff.
- Good checklists should implement a brake or supervisory feature that ensure that vital safety steps cannot be skipped.
Logical Lock helps you reduce accidents and boost productivity through using data to predict and prevent risk. Smart Lock, a “smart checklist” included in the Logical Lock package uses this technology to stamp out hazards in the Lockout process, guiding users through the procedures and blocking access until the task is safe.