Patient Safety and Teamwork: Anatomy of an Accident
Most of us don’t think of our families in terms of teamwork or team leadership and membership. I know I certainly don’t. I think a lot about teams when it comes to colleagues with whom I work. I also think a lot about teams in my professional research. In fact, I am writing a new book entitled Come Fly With Me, with two colleagues — a pilot and medical educator — about team work training in aviation and its lessons for patient safety. In aviation, with the development of Crew Resource Management (CRM) and Threat and Error Management (TEM) the emphasis is on sharing critical information with all of those on the crew — no matter what their position in the hierarchy — in order to prevent terrible accidents. When I work with colleagues or observe the status quo in health care, I am constantly thinking about information sharing — and its lack — and patient safety. I was struck the other day, however, about the application of the team work model to everyday life — life outside of the professional arena, life inside the personal one.
Let me tell you why?
I was in New York, sharing a small hotel room with my eldest daughter, 26, and my husband. We had come from Boston where we live and were spending a few days between Christmas and New Year in the Big Apple. My daughter was flying back to her home in El Salvador and was repacking her bags to leave on an early morning flight the next day. While my husband was out doing errands, my daughter was sorting through her luggage and discovered that the glass on a framed painting she’d brought with her had broken. It had, in fact, snapped into two large pieces — one with a particularly jagged and dangerous point. She lifted out the piece with the rather frightening point, handed it to me and asked me to put it in the garbage. I did. Point up. I then put the less lethal portion of glass into another waste basket. We both knew the glass was in the garbage and we clearly assumed we were the only people with the need to know. It’s not that we decided not to tell my husband and her father. It’s that we didn’t think of it at all. Not for a second.
She finished packing, my husband Steve returned to the room and we all went out to dinner and to a play. We got back and went to sleep, setting the alarm for 3:30AM, as she was going to be picked up to go to the airport at 3:45. I woke up dutifully and kissed her goodbye and my husband took her and her luggage down to the waiting taxi. I blissfully went back to sleep thinking all was well. Which it was. Almost.
When I woke up at about 9, my husband was awake and I asked if my daughter had gotten off okay. She had. She was fine. He wasn’t. What had happened, I inquired?
Turns out, that bleary eyed at 3:30AM, he’d swept something into the garbage and discovered — that is his hand discovered in the most painful way — the jagged piece of glass I’d left sticking right out of the garbage. He’d cut his thumb badly. Not wanting to alarm my daughter, he’d gone into the bathroom to stem the profuse bleeding with some kleenex and then stuffed his hand into a glove so she wouldn’t see it. The person on the desk in the wee morning hours gave him some bandages and he –somewhat uncomfortably — went back to sleep.
You can imagine what I thought when I heard this story and the names I called myself. Not only was my husband’s thumb badly cut,but I was horrified to think that he could have had an even more serious injury if his hand had hit the glass a little lower and he cut the vein in his wrist.
What occurred to me after my initial reaction of guilt and horror, was that I had failed to apply the rules of teamwork, safety, and information sharing that I study to my own family. When my daughter handed me that piece of glass and I put it away, I didn’t think, “you have to warn Steve about this.” Alex and I knew about it and that was, from my own blinkered point of view, all that needed to happen. Not only did I not share crucial information, I didn’t manage a potential threat effectively at all. I deposited that large piece of glass in the garbage point up, when what I should have done is taken it to housekeeping and asked them to safely get rid of it. The threat I had to manage wasn’t only a threat to us, but to any housekeeper who would have to clean up after us. For safety purposes, she was also a member of the team.
Of course, the first thing I did after looking at my poor husband’s thumb was take the two pieces of glass to the housekeeper with firm warnings to be really careful and many apologies for asking her to throw out the broken glass.
But this is how accidents happen. It’s because we aren’t considering who needs to know and because we aren’t thinking about preventing threats to people who are out of sight and thus out of mind. Team theory can help with this. It can be applied to lots of different areas of life. In fact, I increasingly think of the lessons of Crew Resource Managment as Life Resource Management (LRM) . Sometimes, the rules of CRM applied to Life Resource Management is just what you need to get you out of all those pesky patterns you establish over years in a marital or family relationship. Thinking CRM or TEM would certainly have protected my husband’s thumb.