Thread by @DoctorTro

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Safety culture and culture of respect

In the hospitals, doctors words used to be like holy scripture ... nurses, technicians would not dare question anything a doctor said

What happened? Doctors cut off the wrong limbs & left sponges in patients

What went wrong? People who could have help, felt intimidated & didnt

When you examine grave medical errors that result in severe injury or death - there are often MANY layers of defense that actually fell apart that allowed that error to occur

It wasn’t just the doctor who cut the wrong limb

What about the nurse, the anesthesiologist, the tech?

Was the doctor overworked, tired, drunk? Did he have too many back to back cases. Did the surgical team stop and go over the procedure?

It takes a series of calamities and failures of multiple potential defenses for a grave error to occur.

This concept is referred to as the Swiss cheese model of error. Where we need to evaluate every potential defense against a potential mistake to prevent it from happening again.

Interestingly we use this concept quite often in coaching, to help people understand how to rely on other defenses instead of the one that keeps failing (typically impulse control)

Institutions should take errors seriously. They should sit down and analyze what defeneses failed and which ones need bolstering

Likewise patients implementing a lifestyle need to analyze there short comings and figure out how to win. Which defense would have worked?

For patients, it takes significant introspection and confidence to endure this process. First they have to face their failure and not deny it... then share their failure then they have to figure out what’s needed to win next time. This is not easy. In fact it’s painful.

It takes a lot to implement this for institutions. a safety culture and culture of respect is hard to cultivate, particularly in medicine where the culture has been that the doctors words are gospel. Many institutions have rightly worked tirelessly to rid this.

It takes a top down approach to recognize that to win at patient safety... janitors, nurses, techs, anesthesiologists need to be able to challenge physicians if they see something potentially dangerous.

AND these challenges to status quo / prior culture need to be accepted!

There is no way to implement this but from the top down. Doctors won’t just go and allow this culture to be created, it has to be some observing body that recognizes this need and implements it for the greater good, both for patient safety and doctor performance.

I’d like to segue to recent events. To discuss respect/safety culture in our police force

Black lives matter. when challenges are made to police in real-time, they need to be heard, accepted & implemented before another fatal casualty

Regular citizens need a way to be able to fight police brutality/oppression in real-time

One of the many problems with this most recent incident is that regular citizens could have stopped this death, but had they acted against the police officers they would face serious crimes.

Furthermore police need to have a culture that responds positively to real-time questioning of judgement.

Any one of those fellow police officer could have saved a life if they could & did say & do something.

This safety/respect culture comes top down.

Blame their bosses.

When we examine these events through the Swiss cheese model, we see that fellow police and citizens need to be able to tell the police who are making a mistake in real time that something is wrong & they need to be able to hold them accountable in real time.

We need to create a 911 for 911, in case of emergency for the emergency.

Obviously I’m not a policy maker or a police expert, but something has to change. To many people could have saved a life but the prevailing culture was too intimidating & too oppressive to allow challenges to police culture.

I don’t have answers, but those fellow police officers needed to SAY something and it be okay and not penalized for disrespecting command. Those citizen needed to be able to neutralize that police officer, like their better judgement told them to.

I know this is a bit of a rant, maybe it’s scattered thinking, but I hope someone can take some of these ideas and make them into something useful.

Obviously there are other systemic racial disparities and systemic oppression that I haven’t discussed, but these are just some of my thoughts that I wanted to share.

I suspect I’ll lose a million followers

-965,000 followers starting now