Plane Crash is a Reminder of OR Safety Imperatives
I was transfixed by the image of passengers of downed U.S. Airways flight 1549 standing huddled on the plane’s wings as it began sinking into the icy Hudson River where it crash-landed shortly after takeoff. According to a decision sciences professor, the split-second decisions made by the pilot and other rescuers that resulted in no loss of life provide a critical lesson to top management at organizations everywhere. Barry Shore at the University of New Hampshire says the most important factors in the successful outcome of this plane crash were training and skills of those involved with the rescue effort that allowed them to quickly weigh their options and make the best decisions possible. Shore emphasizes it is a lesson about how solid, focused training of personnel can have a substantial impact on the success of an organization. “Training strategy is critical to its success,” Shores says. “Top management must determine what is important. What is the basic message that needs to be delivered and what are the relevant and core skills that need to be emphasized? What are the shared skills that will clearly establish the kind of corporate culture that will help the organization achieve its goals? “Without a clear training strategy, a company is usually left with a collection of unrelated and scattered programs, cobbled together without clear focus.”
In the case of flight 1549, Shore says because everyone had been trained extensively, decisions that normally take longer to make were made in an instant. “Decisions like this, or indeed any personal or management decision, involve several steps, including the collection of data, identification of alternatives, assessment of risks, selection of the most appropriate alternative, and execution of the steps necessary to succeed in reaching the goal. But in most situations, decision-makers have time before they move from one decision step to the next,” he says.
The aviation industry has long been looked to as a model that healthcare should emulate in terms of safety cross-checks and other safeguards. In terms of preserving human life, the operating room is no less critical than air travel yet the number of adverse events in the OR leaves patient safety experts concerned. In an era of budget-cutting, training in the healthcare institution may suffer, thus opening up healthcare professionals to the risk of accidents caused by poor decision-making and medical errors with devastating consequences. And there’s always the general sense of apathy toward training that can hamper the instruction process. Shore notes, “Often, we leave training sessions with the feeling that they may not even be relevant to the challenges we think we will face in the future. Perhaps this explains why most of us pay no attention when the flight attendants review the emergency procedures before each flight.” Shore adds that to be effective, training must be constantly reinforced. “What we learn that we ‘should’ do must become part of what we ‘actually’ do,” Shore says. “We should be able to draw on these lessons in the blink of the eye. Success in execution requires continuous reinforcement. As we have been reminded in this miraculous outcome on the Hudson River, training is serious business. Leave it to chance or abandon training because people claim to be bored and the organization may miss the opportunity to build a focused team capable of moving from good to great.”
Until next month, bust those bugs!
Kelly M. Pyrek
Editor in Chief
