Suspension of the people involved in error rarely (ever?) makes systems safer. Such action is based on the myth that people can, should and must be perfect. It is perpetuated by societies' general call for punishment when someone does something wrong.

In a tragic event such as this one in which an infant died, there are causes at the sharp end - where the care is provided, the exact instant when an error occurs. There are also causes and contributing factors that are distant from the event itself - decisions and designs that establish the resilience or fragility of a system to inevitable human failings.

Apparently the term ghastly was used to describe this error. The real ghastly part of this story is what's behind the response of administration and the journalism that paints such a portrayal.

Why in the world is an error such as this one still possible? And, why is it still seen as appropriate to respond this manner to such a tragic error?

People who care about improvement in healthcare have been forming networks to collaborate, learn and build success for many years. I have had the pleasure to work with one of them, the Quality Healthcare Network. It's based in Toronto, but reaches out globally to find people to learn from and challenge thinking. Here is the latest from their channel on YouTube.

 

The fundamental idea of error-proofing is to make errors impossible. I while back in a creativity session focused on improving adherence to hand hygiene cleanser use, I jokingly suggested that automatic door openers be activated only by the use of a hand sanitizer dispenser. This was in the wake of SARS in Toronto, so hand-hygiene stations at all hospital entrances were the new thing. The safety concept deployed in this idea is that of a forcing function - the next step (entry to room) cannot be performed until a necessary safety precaution is followed. The idea brought howls of laughter, always a cue that an idea is either too wacky to be considered or on a new track to innovation. That was about 5 years ago.
Well, someone has done it.

 

Creativity is vital for improvement and I ask this question during creativity sessions to help raise people's awareness of their own thinking. An article in the Globe and Mail cites recent research (Abstract) providing evidence to why the answer to this question is rarely "in a meeting". It may not surprise you that the answer is typically something like "in the shower", "when cutting the grass", or "driving a quiet road". NO ONE has ever volunteered: "in a meeting". But that's exactly where we're called upon to do some of our best thinking!

Back to the research. I'll cut to the chase with a quote from the author:

"When your mind wanders, a different kind of thinking occurs. When you aren't trying to solve problems deliberately, it provides more mental space, you make connections and let your mind go wherever it wants," said Prof. Christoff. "Driving is the perfect activity for letting your mind wander because it is highly automatized and requires only a small part of our attention. When you daydream, you may not achieve your immediate goal, say reading a book or paying attention in class. But your mind may be taking that time to address more important questions in your life." The research method is actually a fascinating application of fMRI for those who are curious - way over my head.

Next time your team needs better thinking, leave the meeting and defer until everybody gets a chance to daydream on it. I'm now a Daydream Believer (sorry, couldn't resist).