Paul LeSage, assistant chief (ret.) for Tualatin Valley (Ore.) Fire and Rescue, opens his talk about high-reliability organizations (HROs) by telling a story about a law enforcement officer who accidentally shot a naked man out of a tree. The Fire-Rescue Med conference attendees here in Las Vegas were awake for the 8:30 a.m. session in no time.
The story goes that two law enforcement officers were called to a large urban mall where a naked man in a tree had drawn quite the crowd. Fire and EMS was called to standby. Law enforcement officers came up with a plan: They decided they’d have to use a Taser to get the man out of the tree. They asked EMS what they thought about that plan. “Awesome,” was their unified response. The first officer aimed and missed. He instructed his partner to shoot. She did, and she hit the man. As he fell to the ground, they realized she had mistakenly grabbed her gun and not the Taser weapon.
LeSage explained that 74% of errors are caused by a failure to intervene. EMS could have realized this was a poor plan, but they let law enforcement continue. More to the point, the law enforcement personnel were demonstrating at-risk behavior (ARB). One of the factors in this situation was that the law enforcement policy was to carry both their weapons on the same side of their body. Had the policy dictated wearing the weapons on opposite sides, this story might have had a different outcome.
Types of Errors
One of the key points of LeSage’s presentation was to learn to identify and distinguish the three types of errors: human error (HE), ARB and reckless behavior (RB). LeSage is a proponent of not punishing individuals for HE or ARB. Instead, these are coaching opportunities for management.
To a then skeptical crowd of attendees, LeSage introduced the severity outcome bias. He believes the natural tendency is to punish employees for ARBs or HE based on severe outcomes. More simply stated, an entire agency might be pencil-whipping their checklists before the start of their shift, but no one is punished until something goes wrong. LeSage says this just encourages an environment in which employees bury their mistakes, leaving management with little understanding about the problems in their agency.
It’s a difficult balance of accountability vs. punishment. The situation is even more complicated when an employee engages in an ARB because the social benefit outweighs “the rule.” To demonstrate this scenario, LeSage explained a case in which a nurse violated what their hospital called a “red rule.” A red rule is one that cannot ever be broken–LeSage admits he’s still not sure why some rules can be broken.
This hospital’s red rule was that patients more than 80 years old had to be assisted out of bed and into the bathroom at all times. This nurse assisted an 84-year-old patient to the bathroom, but he begged her for some privacy and not to be humiliated by her accompanying him into the actual bathroom. She waited outside after some debate, and the patient fell and broke his hip. The patient’s family filed a law suit, and the hospital fired the nurse. But here, LeSage points out, this nurse was violating a rule for the social benefit of giving her patient respect and preserving his dignity.
Not punishing employees sounds great in theory, but the attendees were skeptical. How do you satisfy an angry board of directors or city councilmen who want to see someone fall on the sword?
Internal & External Imposers
Internal and external imposers are those who keep the rules. Externally, a lawyer may find the ARB or HE negligent, but the internal imposer (e.g., chief) coaches the employee not to make the mistake again and ensures proper training for the entire agency to reduce the ARB.
The key to keeping those external imposers satisfied–which admittedly may be no small feat–is to get their buy-in up front. Involve these decision makers in your event investigation. LeSage provided algorithms to help determine the difference between HE, ARB and RB.
His system means HE results in consoling. Explain to the employee that you’re sorry that mistake happened but also tell them they have an obligation to tell you how to avoid it from happening again and identifying the problem within the organization’s training.
ARBs require coaching. The best kind, according to LeSage, is peer-to-peer coaching. If you can get the entire system involved, it may deter that behavior. So then you don’t have everyone demonstrating an ARB (e.g., pencil-whipping the checklist) and the only punish the employee who left the drug box at the patient’s home.
Finally, reckless behavior warrants punishment. Reckless behavior is a conscious disregard for a substantial and unjustifiable risk. Although LeSage believes these types of errors are rare, they are the type that deserve punishment.
Again, the key is educating yourself, your staff and your external imposers how to differentiate between these errors.
Event Investigation
So your agency has an error. Now what? Now comes the event investigation. LeSage says one of the biggest mistakes you can make during the investigation is to first ask the employee what the procedure requires. He laughs with the attendees saying usually the only people who know the procedure manual back to front are your new recruits. And what happens when a new EMS provider says after a call, “That’s not how we’re supposed to do it?”
Instead of hammering out the policy that no one follows, the better approach is to indentify what the normal procedure is. There’s likely an ARB occurring throughout the agency. LeSage introduces five questions, numbered in both chronological order and order of importance:
1) What happened?
2) What normally happens?
3) What does procedure require?
4) Why did it happen?
5) How were we managing it?
Following that line of questioning will allow internal imposers to identify the problem, tie it to a current practice (likely an ARB), reflect on the actual policy and propose a new solution. Numerous agencies across the U.S. are using this practice to minimize errors and learn from their mistakes. LeSage is happy to give more information to any agency considering a change. E-mail him at plesage@outcome-eng.com.
