Tuesday August 6, 2013 – KEYNOTE ADDRESS by David Marx, author of Whack a Mole, an engineer and attorney, spoke on Why EMS Needs to Stop Playing “Whack-a-Mole.”
He pointed out several big scene errors and noted “who” people want to blame for human errors.
Marx told attendees that, annually In UMS health care, there are 100,000 people killed by avoidable hospital errors. He noted that you have a 1 in 5 chance of being the victim of a hospital error – a rate that is unacceptable – because the public expects perfection.
He share his thoughts and suggestion on how EMS managers could end the blame game and “THE GAME of WHACK-A-MOLE”.
He advised managers to always see the “Two Sides of the Coin”. He noted that we all want to enjoy “Life, Liberty and the Pursuit of Happiness, but stressed that we also have a duty to not injure others,
He used an example from the case of Helen Palsgraf v. The Long Island Railroad (1928), that “Everyone owes to the world at large the duty of refraining from those acts that may unreasonably threaten the safety of others”
When Helen sued because an explosion cased scales to fall and injure her. The court said that we all have a duty to be alert and watch for hazards.
Another example was a hospital’s “falls goal” that causes staff to not allow you to take risky actions and fall.
Marx noted that we have often created expectations for perfection by writing policies so tight that any error made can result in an employee dismissal. He said that words like “Zero Tolerance” exhibit this.
Marx pointed out that missions and values often compete and that everyone can make an honest error, so we should not expect 100 percent perfection
He noted that “Human Error” is an inadvertent action and that “At-Risk Behavior” is a behavior of choice that increases risk where risk is not recognized or is mistakenly believed to be justified.
Conversely, he noted that “Reckless Behavior” is a behavioral choice to consciously disregard a substantial and unjustifiable risk.
He told the Pinnacle audience that the FAA has a reliability requirement that most operations involve a second set of eyes and that this is one proven way to make sure an equipment failure extremely rare.
He advocated that managers “Be Just”, always view human errors as outcomes and not be so quick to punish. He said that “At-Risk Behavior” is the area that managers should strive to reduce.
He concluded that managers should:
1). Console people,
2). Coach people, and then
3). Punish them
