For a guy like me this picture represents a real problem. Some of you are looking at the picture thinking “what’s he talking about” others are thinking “oh man, I get it”.
For those of you who don’t understand life is probably a little easier but to get you on the same page let me explain the conflict. This is a gas pump and it stopped on 10 gallons exactly but the sale price is $39.99. A tap of the pump handle and the price will be $40.00 even – good number! That tap will also cause the gallons to go to an uneven number. In a perfect world the sale price would be $40.00 and gallons 10.000 but it’s not gonna happen so I had to “step away from the pump” knowing that the numbers would not be perfectly aligned.
You wouldn’t know it by my desk most days but alignment and order are important to me. I like all of the shirts in my closet to face the same direction on the hanger. I like the toilet paper to hang on the backside of the roll. I like to follow the same morning routine, wake up, workout, eat breakfast then shower – no matter the day of the week or time of day the alarm rings.
When I was still flying a plane as a hobby my desire for regiment and order served me well. Check fuel level, check aileron and rudder, follow startup checklist, yell “clear prop”, start engine, observe RPM’s and oil pressure, taxi to hold short line, run up engine, add carburetor heat, observe for drop in RPM’s, reduce carburetor heat, observe sky for other aircraft, announce intention to take off, taxi to and align with center line of the runway, add full power, stay in center of runway and then takeoff.
The procedure and checklist followed the same way every time helped to ensure I didn’t miss anything that would jeopardize my safety, the safety of my passengers, plane and anyone or anything below me. Most plane crashes occur before the plane ever leaves the ground, they are usually caused by someone veering from “the process”.
Processes are important to what we do in health care everyday. There’s a reason we do a timeout prior to surgery. There’s a reason we review and mark surgical location with the patient prior to surgery. There’s a reason we inventory instruments following surgery. The reason – patient safety.
In health care processes are important. Processes are created to keep people safe and help us remember to do the things we think we’ll never forget. Most patient harm comes from error and most of those errors are honest mistakes and most of the time they are the result of someone veering from the process. Shortcuts may save time but shortcuts kill people.
When I was flying I had to initiate my startup procedures a full 30 minutes before I had planned to takeoff. I could have saved time by jumping in the plane and taking off which is sometimes referred to as “lighting the fires and kicking the tires” but what if my fuel gauge wasn’t working properly and I hadn’t taken the time to open the fuel tank and do a visual observation of the fuel. When you’re flying at 5,000 feet you can’t pull to the side of the road and walk to the gas station. The same is true of patient safety, once an error is made because we forgot to do something there’s no turning back the clock. Processes are important and for the sake of our patients it’s important that we follow the processes we’ve developed even though it may take a little more time.
We have all the time in the world when it comes to patient safety.