Gordon, can you elaborate on why you haven’t defined any deaths as ‘Avoidable’ in the reviews you have done? Is it the term? The lack of definition? Or another factor?
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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Yes, if there is a good argument behind it. But as many said before, OR is not cockpit. Different variables, people, requirements, but also very different training that brings together other elements of behaviour, culture, shared understanding. That is where HC needs to catch up
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I'm not even sure how to reply to this. Healthcare certainly needs to catch up - I can agree with that part. For what it's worth, I'd be the one getting off the flight. We don't here such conversations in cockpits because unlike healthcare, the pilots go down with the plane.
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*hear* Couldn't leave that uncorrected. It was screaming at me... :)
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But take something like a surgical safety checklist, akin to a pre-flight checklist. If conducting those checks are designed to prevent wrong site surgery for example, surely it's right to regard someone who fails to complete one as having bypassed a known safety measure? No?
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No. Trying to find the latest article that explains why that is not always a valid argument...saw it a few days ago so hopefully can find it again quickly
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By following standards/policies/guidelines people think doing right things, but concentrate on beating the numbers or following the processes, stop thinking for themselves, and lose sight of the intended outcome- Liverpool Care Pathway one example, 4hr A&E targets another
End of conversation
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