By Charlie Carlton, Col, USAF Ret, MS Senior Consultant, Press Ganey Strategic Consulting
A foreign object left inside an Air Force F-35 engine in early 2023 caused nearly $4 million in damages. The item — a handheld flashlight — was sucked into the engine’s air intake during a maintenance ground run procedure.
During an idling portion of the procedure, a team of three maintainers started the engine without issue before going through typical checks, to monitor for fuel leaks. It wasn’t until the airmen turned off the engine that anything seemed amiss. During the shutdown, one maintainer noted “abnormal noises” coming from the F-35 engine. None of the airmen were injured.
The investigation revealed, one of the maintainers carried out a tool inventory check after installing a “metering plug into the engine fuel line.” The process took place out of sequence and before another maintainer used the flashlight to carry out a “Before Operations Servicing” inspection.
Investigators determined the maintainers’ lack of adherence to standard cautionary items highlighted in the Joint Technical Data checklist before the engine run contributed to their leaving the flashlight behind thus allowing it being sucked into the engine and causing approximately $4 million in damages.
How does this apply to healthcare:
Although the event mentioned above is from the aviation industry, Healthcare experiences many serious events like this daily primarily impacting the safety of our patients, team members, as well as family members. For example, each week in the United States wrong site surgeries occur over 40 times, foreign objects are left inside a patient’s body approximately 39 times and these events like the one above is preventable.
In an industry as high risk as healthcare, we have several HRO tools/Universal Skills designed to make sure we all are practicing the best and safest care possible. One of those HRO Universal Skills is to “Know Why and Comply” which ensures our choices are compliant with best practices and the written rules contained in those safety critical policies, procedures, and protocols.
Compliance has always been a cornerstone in a HRO safety culture and the use of well-established checklists as a way to keep patients and medical teams safe. The Checklist is what we call a Continuous Use compliance tool and designed for those tasks or procedures that are infrequently performed, are safety critical, or considered complex/high-risk.
Checklist use/integrity consist of the following actions: first making sure you have the most updated version; ensure the entire team reads and understands the entire procedure before taking any action; the checklist is present (on hand) at the procedure site and read directly by the user or designated leader; it’s conducted in sequence and verbatim; finally use STAR (Stop/Think/Act/Review) to think critically and initial off every step.
As healthcare continues to march towards a goal of ZERO preventable harm, we are seeing several medical professionals using multiple methods founded in well-established HRO Universal Skills to reduce patient harm and eliminate medical errors. One method being implemented more and more is the checklist. As noted from our safety event in the beginning of this blog, the checklist is just a tool and its effectiveness depends on its quality/thoroughness, the acceptance and compliance by the entire healthcare team, and having a strong culture of safety must be present within the organization being embraced by its leaders.
To learn more about HRO Universal Skills and Behaviors reach out to Charlie at charlie.carlton@pressganey.com