On this blog we have seen the analogy of swiss cheese to safety in the form of James Reason’s swiss cheese model of failure. Now what could cookies, as yummy as they are, possibly have to do with safety?
Yesterday, I walked up to the city marketplace after work to get a snack: Chipyard cookies were calling my name. As I approached the stand, I recalled a story from a colleague who was fired from this company in college. It seems after baking the cookies, the staff were required to take the hot trays from the oven and load them onto to a backing rack. The procedure would be to yell “hot tray” and then slide the tray onto the rack to cool. Several times, my colleague yelled “hot tray” and as she was placing the tray into the rack she would use a bit too much force and the tray would slide out the back of the rack through an open window panel! The “hot tray” of cookies would drop out onto the pavement behind the cookie stand rendering them unsellable.
She was shown the “safety” procedure several times yet somehow the cookies kept ending up on the pavement. Thinking she hired a bad apple, the manager fired my colleague who is now an incredible nurse who saves kids’ lives…bad apple indeed.
When I walked up to the cookie stand last evening I noticed something amazing. They had built a small wall right behind the cooling rack! I asked the girl at the counter “Hey does anyone ever ruin the hot tray of cookies by knocking them through the rack?” She looked at me increduously! This new generation of workers could not even conceive of making an error of this type. This is forced function at its best and illustrates the effectiveness of this type of intervention over education and prompts to do better to eliminate safety hazards.
Do we have similar situations in healthcare? Are we telling staff over and over “Don’t make this mistake” “watch what you are doing!” “be more careful” or are we building barriers to unsafe actions and behaviors that will create and sustain safety for our patients?
I can think of one success in particular. Seasoned nurses will talk about the old days when they mixed chemotherapy in the kitchen on the inpatient units. New nurses will listen with horror as they only know chemotherapy that comes in specially prepared and labelled containers from the pharmacy.
Real safety comes from designing safe systems and critiquing everyday provider choices and behaviors (Just Culture Community, 2008).
Look around your environment. What safety hazards/behaviors could you render obsolete for the next generation?
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