This is a really important read about safety in the medical domain, but crosses effectively into others domains where safety is of critical concern.

I had the privilege of working under two captains on the NOAA Ship Fairweather that promoted cultures of safety similar to the “Stop the line” culture that Dr. Watcher describes. We often performed dangerous tasks as a matter routine that could easily have proven fatal. There were only a handful of times that I ever felt unsafe, but most importantly I always felt empowered to bring safety concerns to the command, and trusted that they would be addressed appropriately. Which could be anything from a simple explanation to a break in operations.

The “Stop the line” philosophy, widely associated with Toyota manufacturing facilities, is a culture “in which every employee knows that she must speak up — not only when she’s sure that something is wrong, but also when she’s not sure it’s right.” And where “no one should ever have to worry about looking dumb for speaking up.”

While that sounds simple, in practice it is a lot of effort to build and maintain that culture. At it’s heart it’s built on respect, a respect that is sorely lacking in many cultures not directly related to safety.
How Technology Led a Hospital To Give a Patient 38 Times His Dosage

When Pablo Garcia was admitted, he felt fine. Then the hospital made him very sick. Blame high-tech medicine.

cross-posted on Facebook