Updated: Jan 28
I recently had the pleasure of attending an airshow, as a guest of my husband, a military pilot and astronaut. As an obstetrician and gynecologist and a MOREob trainer, it was with great curiosity and intrigue that I was able to observe a debriefing for our Air Demonstration Team, the Canadian Forces Snowbirds.
As a MOREob trainer since 2004, I have been presenting slides and videos that hi-light how medical errors are preventable using principles from High Reliability Organizations such as the aviation industry but until this weekend, I had no idea just how applicable, yet difficult to implement, these principles really are.
The Canadian Forces Snowbirds put on a spectacular show. It was precise, sharp, clean and very, very beautiful. I was awestruck!
And then I attended the debrief and my delight turned to absolute shock. As a physician who carries out complex procedures with a healthcare team regularly, I was not prepared for the discussion that followed.
Utilizing an unforgiving video replay, the Team Lead, Major Wayne Mott asked if there were any identifiable safety issues during the routine. A few pilots started to describe some minor issues that could have led to events (ie. No harm events), and the Team Lead evaluated this discussion as the team took individual notes. Nothing significant was identified and they moved along.
The second step was even more remarkable as each member evaluated his own performance identifying even slight miscalculations for others to watch, consider and comment. I sat in amazement as pilots, with rather large egos by nature, openly revealed the inner workings of their personal show with the goal of indicating to their team members that they could see the strengths and, more importantly, the weaknesses in their performance. They debrief after EVERY practice and EVERY show all year long. They don’t skip the debrief when they are exhausted, busy, missing their families and trying to get home. That would be a direct insult to their fellow team members.
To the untrained eye, the show was a miracle in the sky. There were no errors to be seen and I sat bewildered at the honesty in the room during debriefing. Any one of those pilots could have easily hidden their tiny mistakes and no one would have known, each busy flying their own part.
In medicine, if everything goes well, as it usually does, how often do we, as a team, discuss what COULD have gone wrong? And more interestingly, how often do we identify our own errors in front of each other, placing them in the open for scrutiny? Consider doing this after EACH delivery and surgical procedure even if everything went “perfectly” well.
In talking with a few of the guys after the show, I asked why they were so tough on themselves, talking about minor movements that had no real impact on their overall performance. They described to me a culture of professionals that actually LOSE integrity and the respect of their team if they DON’T see and discuss their own errors. It is seen as a trust issue.
“If you can’t see your own errors there is a good chance that someone else will and then you will lose credibility. If you can’t see your inaccuracies then you certainly can’t be trusted to fix them.” I was told by one tall, handsome man in red.
After teaching MOREob for eight years, and being married to a pilot for 10 years, I thought I understood the relationship between medicine and aviation. I now realize that aviation still does HRO principles so much better than we do, that we continue to have a lot to learn from them and that even arrogant, seemingly difficult personalities in medicine can learn to change their culture. That changing the culture of how we view our own personal errors and our expectations of each other must continue to evolve if we are to keep patients safe in our hospitals.
One pilot told me he witnessed the vaginal delivery of his baby and, after a delay to cry she was whipped over to the warmer, assessed and handed back to his wife. He thought all seemed well but was uncertain about what had happened and, as a good aviator would, waited for the debrief. The doctor walked out leaving him and his wife to wonder what just happened and how their little girl rated on her entry into life. Was it nominal? Abnormal? What should they expect? What should they watch for? He was awaiting communication from the commander in the room. He had just observed a beautiful entry of life into the world and was left with emptiness and even some fear. As physicians, we know that if things weren’t okay, the doctor would have stayed longer but my pilot friend didn’t understand the culture of a profession that walks away from an event so amazing and doesn’t talk about whether all was as expected.
The airshow events have renewed my motivation and my hope that we can eliminate preventable errors in our profession too. We are not there yet but, thanks to Salus Global and MOREob, we have started down that road of culture change, acceptance and recognition of human error and distribution of tools necessary to make the delivery room as safe as the sky.
For permission to re-publish please contact Dr. Catherine Hansen at firstname.lastname@example.org.
For more information about Salus Global go to Moreob.com