En route to #dasMACC this year, I had the incredible opportunity to visit colleagues at Air Zermatt (@airzermatt) in Switzerland. With an exceptional view of the Matterhorn in the distance, the base situated at 5,310 ft, is home to one of the worlds most famous aerial search and rescue teams. You can see more of the team here.
Joining the crew for a weekend shift, I was immediately outfitted with the appropriate attire, toured around the facility and oriented to the aircraft and equipment. A safety briefing was provided as well as through debrief on the operations. While our helicopter rescue program is similar in terms of winch procedure and technical language, we are vastly different in environment, equipment and regulatory framework.
Once properly pre-briefed and prepared I was ready….. to wait.
Waiting is the cornerstone of the prehospital/rescue environment. This time of heightened awareness was filled with observation of the staff interacting with one another, with discussion about practice, debates and story telling. The prevailing theme in all of their stories, is a palpable commitment to their craft. Be it a pilot, doctor, paramedic, rescue specialist or mechanic, it appears to be the same.
There is a very acute awareness about the danger of their mission; it is a healthy respect but it does not induce paralysis. I gather, as many in the search and recuse community do, that they have each reconciled their own individual risk and mortality long, long ago. To work in these sort of hyper dynamic, high risk environments, the reality is, that even with the best gear, highly trained personnel and all of the safety mechanisms in place, we are human; and humans make mistakes.
The prevailing theme observed was that of mutual respect. While just as in every organization they have different personalities (some more challenging than others), they hold each other’s skill set in high esteem.
The most lovely observation made was their willingness to share mistakes. Not just internally, but to an outsider. Their pride is balanced with a healthy dose of reality. They are unapologetic and honest about how and why things are done, the strategy and intent, freely admitting that there are problems that they have not yet solved. 
Though never officially named, the concept of “Just Culture” came to mind as they told of the near misses, and errors that are confounded in their harsh environment. There was never a “who” but rather a “how” and “why”. This sense of shared accountability both of the individuals and the organization.
In an environment where three aeriall mountain rescues/evacuations in 24 hours was considered a “slow” day, this willingness to share mistakes and learn from them, has no doubt saved lives.
In the US, about five years ago, just culture was the latest buzz in healthcare. Years later though, it seems that it never really took hold, that errors in healthcare are rarely looked at from a system prospective but rather as an individual failure of the clinician. The litigious nature of our society could be the reason (at least in the US) but what of the willingness of leadership to admit institutional failure?
Even more important, spreading the message of the error so that it can be disseminated and learned from. The aviation industry does this really well. Accidents and errors are investigated and the conclusions are widely distributed in the hope that pilots and crews from around the globe learn from catastrophic errors.
While writing this post, I came across this tweet.
When I read it, I immediately felt angst for this person. I immediately worried for them. Will they be sued or fired or ridiculed? I worried that Twitter would attack and that something awful would come to them and I don’t even know this person! Fortunately, Twitter didn’t fail me. The responses were kind and encouraging, focused on empathy and positive future change. All of the suggestions for change were centered around the system and not the individual.
The individual recognized the error, they were aware of their failure. A reprimand does nothing to solve the problem. But an overview of the systems in place that lead to the problem might. The human factors, the ergonomics, the process all deserve a look, in this or in any situation where errors occur, particularly those in high stakes environments.
I then wondered what this means for us as educators? When our students, interns, registrars, make mistakes? Do we look at the system we have created for them? How we have taught and mentored them? Do we consider that our methodology or process could be flawed? Do we view ourselves as part of the larger system of their education?
I don’t have an answer. Mostly, I just have more questions. How does an organization harness that culture in the way that Air Zermatt has? There are books and courses, sure, but I have to believe that it comes from the willingness of a group of committed professionals to come together focused around shared organizational values and a leader willing to model the behavior.
I am interested in your thoughts. How do we create cultures who willingly share their errors so that others may learn?
vb
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We just instituted Just Culture and sentinel event reporting at our rural EMS agency in the US. N=2 so far, but buy-in from administration, a standing committee that performs a root cause analysis with a heavy emphasis on systems and processes, and lots of communication to our providers on the results of incidents and near-misses, emphasizing the system changes and praising the individuals for self-reporting, has at least resulted in no pushback to Just Culture and a system focus to error. With time and more examples, my hope is that our culture will grow.
Hi Ashley,
Good piece. Managing error and the outcomes thereof is something we’ve struggled with as a profession and a society for a long time. I’ve just stepped off the unit floor having had a chat with one of our more experienced registrars who I tasked with presenting the topic of “How to fail” last June at our weekly education session. Having first worried that there was a particular reason that I gave this topic to him, he went on to give a great presentation that dealt with many of the themes that get discussed amongst the FOAMed and other communities.
It turns out that the effect of that talk did not end with the last slide.
Off the back of that presentation, he and another registrar have set up a regular ICU trainee peer session where they come in an hour early before the evening shift, bring in a few pizzas and talk through any difficulties that are being had, barriers that are being faced or errors that have occurred, similar to your description of Air Zermatt. They also go over the wins, successes and aspirations to glean learning points that all may benefit from; as advocated by Chris Hicks to make good practice a habit.
The session is a consultant-free zone to encourage open discussion among the trainees, with the two founding registrars acting as a conduit to annonymously bring concerns and suggestions to the consultant group as needed.
They’ve had a few of these sessions starting last month and so far it seems to be going well. We may even see the benefits of this spread across the wider unit population with regard to clinical practice, education and perhaps overall career happiness (Too lofty?).
Take care
Matthew
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