Thank You For Pointing Out the Mistake

One of the greatest accomplishments of the Aviation Safety Model (ASM), Crew Resource Management (CRM) has been the creation of what Schein and Bennis and Edmondson have called “psychological safety” in the airline industry.  Moving from a culture that was characterized by the authoritarian (rather than authoritative) exercise of power, to one in which it is safe to tell someone — even someone higher up — that they have made or are about to make a mistake, was central to the creation of airline safety.  As my co-authors airline pilot Patrick Mendenhall and medical educator Bonnie Blair O’Connor and I have written in our book Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety, creating a psychologically safe environment takes a lot of work — both initially and over time.   Because of this work, aviation culture has moved, as former Vice Chairman of the National Transportation Safety Board Robert T. Francis has described it from a culture in which the captain would convey, implicitly or explicitly that “I’m captain, I’m king.  Don’t do anything!  Don’t say anything! Don’t touch anything! Shut up!” to a culture where the message is “I’m captain, I’m king, please tell me if you see me making a mistake!”

This redefinition of how power is wielded has transformed a “just who do you think you are culture?” into a “thank you for your input culture.”  Which is precisely what one sees when one looks closely at the relationships between airline personnel, as the story I’m about to tell reveals.

Several months ago, my friend and colleague Julia Halissy, a dentist by profession, and prominent patient safety advocate and co-founder of The Empowered Patient Coalition, was sitting at the airport waiting to take a flight.  The gate agent had not yet arrived to take his or her place at the gate but soon after Dr. Hallisy sat down, an airline captain arrived.  He saw no gate agent at the counter and left his bags there, and then walked over to a seat and began working on his computer.  A few minutes later, the gate agent arrived, went up to the counter and noted, with alarm, the unattended bags sitting there.  She looked at the baggage tags  and discovered they were the captain’s.  She marched over to where he was sitting, and at this point, Dr. Hallisy thought to herself,” Oh my, this isn’t going to be pretty.  She’s going to tell him he left his bags unattended and he’s going to ream her out.”  That,  after all, is what she knew would probably happen in a hospital or other healthcare setting should a so-called subordinate remind her or his superior of a problematic practice.  But this was aviation post CRM and Dr. Hallisy had a surprise coming.

The gate agent did indeed tell the captain about his unattended bags.  Instead of reaming her out, however, he looked up in surprise and said,”Oh my goodness, I’m so sorry, thank you for letting me know.”

Imagine if that happened all the time in health care.  Imagine how many lives would be saved, how many complications prevented, and how much more satisfaction people would have from their jobs.  All it takes is a simple “thank you,” or “please tell me if you see me making a mistake” and, like the famous Butterfly Effect, cultures can slowly but inexorably, begin to change.


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