Dirty or Clean? Why Health Care Need to Learn from Aviation

In their book Managing the Unexpected: Assuring High Performance in an Age of Complexity, Karl  E. Weick and Kathleen M. Sutcliffe outline the characteristics of a High Reliability Organization (HRO).  HROs, they explain, are preoccupied with failure, reluctant to embrace simple interpretations of problems, sensitive to operations (i.e. the frontline where work takes place), committed to resilience, and always defer to expertise (even when that expertise comes from people low down on the organizational totem-pole.

HROs also “worry a lot about the temptation to normalize unexpected events” and thus respect “feelings of surprise.“  People who work in HROs are, as they describe it “mindful.”  “By mindfulness we mean the combination of ongoing scrutiny of existing expectations, continuous refinement and differentiation of expectations based on newer experiences, willingness and capability to invent new expectations that make sense of unprecedented events, a more nuanced appreciation of context and ways to deal with it, and identification of new dimensions of context that improve foresight and current functioning.”  HROs always pay attention to human factors, which as Kim Vicente explains in his book The Human Factor, are  the “problems arising out of the relationship between people and technology, not just at the level of the individual but also at the organizational and even political level.”

As we have argued in our book Beyond the Checklist: What Else Health Care Can Learn from Aviation Safety and Teamwork, aviation shares all the characteristics  of an HRO outlined above.  Because of three decades of mindfulness about safety, aviation, once a very high risk industry, is now a high reliability one.  The other day, my co-author Patrick Mendenhall and I were talking to two former aircraft accident investigators  Douglas Dotan and Ron Schleede .  Both were at work several decades ago as the aviation safety model (ASM) of Crew Resource Management (CRM) was, no pun intended, just getting off the ground.  They had first hand experience of investigating some terrible airline crashes. 

Today’s airline accident investigators, they told us, don’t have the wealth of information they had.  Why not?  Because the ASM has been so successful that there just aren’t that many accidents to investigate.  To Patrick and I, that unarguable statement tells us why health care should learn from aviation safety.  In health care, the same accidents just keep occurring year after year, decade after decade. Because health care leaders have not cultivated and encouraged the kind of mindfulness about safety – both individually and institutionally – that there is in an HRO like aviation.

The following story illustrates the problem.

About two days before we talked to the former aircraft accident investigators, we talked with a friend whom we’ll call Carolyn, who is an experienced nurse on an orthopedic unit at a major US teaching hospital. She had just come off her shift and was disturbed by an experience she had while at work.  During her  shift, a float nurse (an RN who is not attached to a particular unit but who is assigned or “floated” to that unit to fill staff shortages) whom we’ll call Pat, asked our friend where to find an IV pump.  Carolyn told her that they don’t keep usually keep clean pumps on the unit and instead call down to Material Services to get a pump.  At this point another nurse, we’ll call her Joan, jumped into the conversation and told Pat, the float nurse, that she could find an IV pump in the dirty utility room.  Quite alarmed at this idea, Carolyn warned,” if you take an IV pump from the dirty utility room, then you’ll have to carefully disinfect it and it might just be easier for me to call down and get you one that’s already clean.”

Joan, then said, ”No, just take one with the clean sticker on it from the dirty utility room.  They have them in there.”

Carolyn, was even more alarmed at this.  “Well, you can’t assume that an IV pump with a clean sticker is still clean and hasn’t been used if it’s in the dirty utility room.”  It turns out this is precisely what Joan had assumed.  It seems that there is a well developed process to indicate that reusable equipment –I V pumps, monitors, the pump like devices put on patients’ legs to make sure they do not develop a blood clot etc — are clean.  Once they are properly cleaned (which means not just neat and tidy but disinfected) the cleaners put on a colored sticker that says clean and that is dated and initialed by whoever cleaned the equipment.  Problem is there is not a clear process – or at least not one that is clearly understood — about taking those stickers off once equipment is in use.

This is what Carolyn suddenly realized.  Anyone, could put an IV pump with a clean sticker on it into the dirty utility room.  It could be put there because it had been used and needed to be cleaned but no one had taken the sticker off.  It could really be clean – because it had been in a patient’s room but had for some reason not be put to use – and someone like a nursing assistant had stowed it away in the dirty utility room.  It could have been left in a hallway  — either clean or dirty –and put in the room by a housekeeper.  Any number of people – and variables — could have conspired to create this kind of confusion.  But the confusion really stemmed from the fact that there was no agreed upon process that everyone understood about what happens to stickers on reusable equipment once it is used.

Carolyn could not tell us whether or not there was a written policy on the removal of these clean stickers.  There might be some piece of paper somewhere outlining this process.  Or maybe something was sent out to staff.  What she did know was that no one had ever explicityly talked to her about removing the stickers.  Joan told Carolyn she had no idea she was supposed to remove these clean stickers once equipment was in use.

Carolyn, who is very mindful about safety, said she always removes clean stickers on equipment when she sees them. But not everyone does, as this story reveals.  What this means is that people who are very well intentioned and otherwise serious about safety could inadvertently grab a dirty IV pump and think it’s actually clean even though it’s in the dirty utility room because it has a clean sticker on it.  So the clean sticker could trump other information — like the place where the equipment is located – which is for things dirty.

When I recounted this incident to Patrick the next day, the first thing he said was, “You mean they don’t take the clean sticker off immediately when the equipment isn’t put in use?  That’s not on the checklist?”  This, of course,  because of Patrick’s 30 years of experience in an industry that has become mindful of safety.

No, I answered, that’s they problem they don’t.  And by the way there is no checklist, or process, or protocol. Or if there is one it is apparently so invisible that people don’t know about it.   The fact that such a policy might be written on some piece of paper in this hospital is essentially meaningless if people are unaware of the policy or ignore it.

Reading this story someone might be tempted to blame the nurses or aides or whoever puts something clean in a dirty utility room, or someone who would take something that says it’s clean out of a dirty utility room.  That would be to misunderstand both the problem and why we relate the story.  What is important about this incident is that it reveals a lack of mindfulness about safety and the human factor not only in this institution but in so many others. Some nurses, like our friend, take the stickers off.  Others don’t. So a patient’s fate is entirely dependent on the luck of who is in the room, and what their individual attitude/mindfulness is toward infection control and safety.

This is a larger system problem – one that indicates a lack of institutional, not just individual, mindfulness.  If the process for putting on clean stickers was designed with the putting the sticker on in mind as the end point but without considering the how the stickers will be removed so people know something once clean is now dirty, this is a design flaw that needs to be immediately rectified.  If those who designed the sticker process did design a process through which they should be taken off but no one knows about it and it is not routinely referenced, re-referenced and cross-monitored this is also a design problem – a system problem.  Which in turn leads to questions about leadership and management of safety issues within the institution.

It is worth restating that this is a real problem, not just in this hospital, but in many, many others.  Go to any hospital, ask any front line worker and they will identify problems like this that point to an epidemic lack of mindfulness and awareness of the importance of human factors in health care.  This may explain why, in a recent study of nurses in the US, the UK, and China, 41 percent of those surveyed said their hospitals were unsafe.  Ninety four percent of the nurses surveyed said their hospitals have programs in place to promote patient safety, but only 57 percent said they believe the patient safety programs in their hospital were effective.

Both this story and survey point to another reason hospitals need to learn from the ASM.