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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Replying to @Cjw450Cathy @C7RKY and
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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Replying to @Cjw450Cathy @C7RKY and
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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Replying to @Cjw450Cathy @doctorcaldwell and
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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Replying to @C7RKY @doctorcaldwell and
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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Replying to @Cjw450Cathy @doctorcaldwell and
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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Replying to @C7RKY @doctorcaldwell and
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 despite1 reply 0 retweets 0 likes -
Replying to @Cjw450Cathy @doctorcaldwell and
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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Replying to @C7RKY @doctorcaldwell and
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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Replying to @Cjw450Cathy @doctorcaldwell and
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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