ZHH you were asking about a definition of Avoidable Harm, Gordon?
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That’s where problems lie, John. There may not be pre-existing ‘safety measure’, or may not be most appropriate in that particular circumstance. It may have been produced/implemented by people who aren’t actually doing job, and not be fully aware of realities at sharp end.
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And that‘s typical thought process that leads to blame culture, whether we expect it to or not, by nature of thought process, as you said yourself...”So if it does, somebody bypassed a known safety measure designed to prevent it”
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Look far enough, always ends up blaming individual. But what if the ‘Safety measure’ was faulty, inappropriate, misapplied, hidden away in some obscure location? Individual still gets blamed for not adhering to it. Nothing changes, no winners, only losers all round
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Woah.. blame is a whole different conversation. That's where the circumstances of why something happened get explored. But it should not alter defining what happened as a known safety measure being bypassed. If the measure is faulty/inappropriate then doesn't fit the definition.
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But, if I had not raised it, would you have questioned the validity of the ‘Safety measure’ before stating causation? I fear not. Few do
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I hinted at it when I mentioned the 'watering down' of the list, so yes, I do have questions on some now. But number 1 on the list of Never Events since it began has always been wrong site surgery. And I can understand how a surgical safety checklist can prevent that, if used.
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But as important as Checklist is culture/communication in team, shared understanding, mutual respect. Checklist ‘forces’ some ideals, but also forces teams to work in ways not always best in real situations
shortcuts taken, distractions happen BECAUSE of checklists, not despite -
Imagine you're going on holiday. Somewhere hot (for a change). As you're boarding the flight you overhear the pilots expressing a similar view about the pre-flight checklist. Would you still take your seat, happy to let them decide whether it's best to do the checklist or not?
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