For the remainder of the week we will be featuring post from the HFES 2015 Annual Meeting.
This year’s keynote will be presented by John Nance during the Tuesdaymorning Opening Plenary Session. Nance is a well-known advocate of using the lessons from the recent revolution in aviation safety to revolutionize the patient safety performance of hospitals, doctors, nurses, and others within the health-care domain. His talk, entitled “The Carbon-Based Conundrum,” will deal with the concept that it is only through accepting the inevitability of error that we can eliminate human-caused disasters. As
Nance puts it, “The key to zero disasters is zero denial.”
I was eager to hear John Nance’s keynote address this year because it was on a topic that I have advocated for a long time. Why does the aerospace industry have such a great error reporting safety management process while health care spent most of its history sweeping errors under the rug? In my own work, I have found such stark differences in the organizational cultures, safety climates, and risk management perspectives that it really is no surprise that they would be so different. But if we put some brilliant minds to the problem, can we take any lessons from aerospace and apply them to health care?
John Nance has the credentials to give me hope that he is up to the task. I wasn’t familiar with his work before seeing his name on the HFES agenda, but a brief look at his biohad me convinced. At least worth a listen.
I was not disappointed. He was an engaging speaker who shared several stories from his military years and even riffed a little on Star Trek. He likes the model of Jean-Luc Picard over Captain Kirk as a leader in a safety-critical domain. If you don’t understand the analogy . . . well I guess you should have come to the keynote address ☺. He also had some good analogies with professional baseball where getting a hit one-third of the time (67% failure rate) puts you at the top of the league.
Despite the fact that he comes from a non-human factors background, he demonstrated a good grasp of human factors science. My favorite message was his recognition that the so-called “human error” explanation for most incidents is really a problem with a system that is not designed to consider the well-established limitations of human cognition and behavior. Of course we all knew this already – but it is good to hear it from someone who frequently speaks to the mass media and general public.
My other favorite message is that preventing all errors is impossible, so a resilient environment is one that is quick and reliable in the recognition and mitigation of errors when they occur. The goal isn’t zero error (or zero defect) but rather zero damaging outcome.
Did you make it to the Keynote Address? What was your impression? What was your favorite video (I am torn between the Simpsons lie detector and the nail in head)? Let’s turn this into a collaborative post.
If not, do you have any stories to share about aerospace or health care safety?
Image Credit: SJ State HFES