By Steve Kreiser, MBA
Partner, Strategic Consulting
In the past we have included a story in our Universal Reliability Skills training about a man who worked for Stanley Steamer who left his child in his car after driving past the daycare center and forgetting to drop her off (defined as a skill-based lapse). It was a tragic story, but unfortunately, I still see these types of events in the news all the time. Here is a link to one that happened recently in New York.
Unfortunately, his is not a new kind of tragedy. This Washington Post article from 2009, relates a heartbreaking story about another child left in a hot vehicle. This article is worth the read, with good references to James Reason and how the Generic Error Modeling System helps us to understand human error.
You can use this story and everyday examples of errors, accidents and events to help communicate the nature of human performance, human error and error prevention (Reliability Skills) to your staff and providers. I always tell the people I work with, “This is why it is SO important to develop STAR as a strong habit, even when driving (checking blind spots, ensuring doors are locked, and checking the backseat when travelling with children).”
Having triggers helps as well. I had a nurse tell me years ago that she would always take off one of her shoes and place it in the backseat with her baby to ensure she would never leave her child in the car by mistake. Essentially, she was forcing herself to do a good STAR self-check every time. If you find it too much trouble to take off a shoe, you could also put your keys, phone or wallet in the backseat which would also create a forcing-function to check your backseat when driving with an infant.
As I get ready to have my first grandchild in September, I think I will adopt this kind of practice whenever I’m driving with my grandson to help avoid the type of terrible tragedy that has forever changed the life of the grandmother in New York.
I know the use of STAR to self-check can help avoid skill-based errors in hospitals and other healthcare settings where staff and physicians are rushing, multi-tasking, fatigued or distracted. Encourage the people you work with to develop it into a practice habit and become a good proponent and role model of it in your everyday life as well. Share stories of how STAR moments have resulted in great catches in your organization, or maybe how it should have been used to avoid an event of harm. Start your meetings and huddles with these stories or talk about them when out on rounds. This type of messaging is a critical HRO Leader Skill to help build culture and reinforce accountability, all necessary for sustaining high reliability healthcare.