ED Sign

Oh, and by the way, try not to kill anyone.”

The origins of this quote will become more obvious later but it sums up the challenges of a busy, chaotic day in the emergency department or any other high reliability organization (HRO).  Last week I introduced the concepts of high reliability organizations and how they relate to the emergency department (See Managing the unexpected – great resource on HROs):

  1. Preoccupation with failure
  2. Reluctance to simplify
  3. Sensitivity to operations
  4. Commitment to resilience
  5. Deference to expertise

This week I will focus on the first – preoccupation with failure. We will look at an example of who does it well and what we can learn from them.



  • Encourage reporting of errors
  • Use near misses! – Treat any lapse as a symptom that something may be wrong with the system
  • Accept that small failures can have an additive effect and lead to Natural Accidents
  • Continually articulating mistakes you don’t want to make.

Naval Flight Operations

naval flight operations crew

“So you want to understand an aircraft carrier? Well, just imagine that it’s a busy day, and you shrink San Francisco Airport to only one short runway and one ramp and gate. Make planes take off and land at the same time…rock the runway from side to side, and require that everyone who leaves in the morning returns that same day…Then turn off the radar to avoid detection… fuel the aircraft in place with their engines running, put an enemy in the air, and scatter live bombs and rockets around. Now wet the whole thing down with salt water and oil, and man it with 20-year-olds, half of whom have never seen an airplane close-up.

Oh, and by the way, try not to kill anyone.”    Naval War College Rev 1987 40 76-90

                                            — Senior officer, Air Division

How seriously does the US Navy take safety?  In 2006 after a series of incidents that killed 10 aviators and destroyed nine aircraft they ordered a complete stand-down of all aircraft for a half a day, including those on all 12 aircraft carriers, for an internal safety review.

More recently after a “Bent Spear” (misplaced  nuclear weapons) incident identified significant lapses in safety and procedures a series of resignations occurred starting with the Secretary of the Air Force.

On the flight deck this preoccupation with failure extends to:

  • A culture obsessed with finding failure (anyone can shut down the flight deck if they believe safety has been compromised).
  • Every landing is televised, reviewed, graded, and grades used to improve performance.
  • Everyone sees how everyone else performs.
  • Near Misses are debriefed within the hour and are treated as signs of potential larger problems.
  • A tradition of all ranks walking the deck every morning looking for defects and stray objects (think unsafe working conditions).

Emergency Department Lessons

So what can we learn from all this? Where is emergency medicine and emergency nursing on preoccupation with failure? In some ways this may be our weakest. Medicine has a tradition of pointing fingers when errors occur rather than reward those who bring them to light. We also tend to be great at preventing small errors (nurse: doctor did you really want to order 4mg of dilaudid on the 95 year old and not the patient in sickle cell crisis patient next door?) rather than fixing the recurring cause. This must change in ways both large and small.

At our shop these are some of the ways we have tried to improve:

 EDQA Process  (See previous post: http://wp.me/s2RkOX-edqa)

  • Weekly meetings that include active physician and nurse participation.
  • Over 700 charts reviewed in three years.
  • Outlet for staff to report concerns on care and near misses.
  • Significant contributor to fixing system issues and prevent small errors from becoming larger ones.
dont drop ball

Flattening of Authority Gradients

  • We called it:  DON’T DROP THE BALL Program
  • Others use TEAMSTEPPS or CRM (Crew Resource Management)
  • All have the focus on making all members of the department an active part of the care team with a voice on safety.

Next week I will be covering HRO Principle #2 (Reluctance to simplify). In the meantime a related slide set can be found at: HRED