Last issue I carried the inspiring story that I heard first hand from a Kargil war hero, Capt Naveen Nagappa. This time I want to share lessons from a talk that I heard from another type of war hero – a cardiac surgeon who likens a surgery to a war field, given that in both cases there is zero tolerance to errors. After all it is literally a ‘life and death’ question.
I heard the renowned heart surgeon Dr. Vivek Jawali speak on “Lessons in heart surgery – Zero errors in management”. These were practical lessons from a ‘little-giant’ (a person of petite stature but a towering personality) who has 30,000+ surgeries to his credit. Sharing a few snippets …..
- Flight, Cardiac Surgery & War – all have variables though flight is predictable. Cardiac surgery & War can be fluid and challenging.
- Best practice – zero error and open mind.
- Although individuals may make mistakes, it is possible for teams to be flawless – Teamwork.
- Humans cannot be punished for systemic errors – create a culture of fearless error reporting (role of whistle blower)
- How zero error is ensured in pre-operative stage – diagnosis & layers of counter-checks before admission, fast track tests, cross-discipline consultations, pre-procedural plans, check listing, quick calls, multiple cross checks by all team members (sounds like a corporate project preparation, right ?)
- What are the reasons for error in Operation theatre / ICU – Lack of adequate training, absence of standard rules, major gap in communication between surgeon and others, use of unreliable systems, rush to complete cases due to bad time management – ANSWER to all these maladies is EDUCATION, CHECKLIST, COMMUNICATION (corporate or cardiac surgery lessons ?!!)
- Errors in other areas – general diagnostic, medication, device & equipment, hospital acquired infections, electronic health records, communication, handing over patient, during acute intervention – all of these can be prevented through SOPs, communication protocol & solid team (it is nothing short of a war room !)
- Politeness in communication is a NO-NO in a surgery room – could be fatal for the patient at times
Mantras for safety promotion & zero errors
- Build better teams
- Build safeguards
- Be conscious of similar sounding people names in OT (could be disastrous)
- Reduce time to report abnormal test results (use phone, whatsapp)
- Give time-out or quiet zone to the nurse
- Ensure team members accept inherent issues in their roles
- No room for ego when errors are reported
- Hierarchy to be rigid and respected
- Prioritise, expect the unexpected
- Create a fair and fearless environment for whistleblowing / error reporting
Develop thorough checklists | Foster a solid team | Encourage clear communication |
It was mind-blowing to listen to this management talk from a world renowned cardiac surgeon – so many takeaways and tips that each one of us can adopt for Zero Errors.
While Dr. Jawali interspersed his talk with amazing live stories and anecdotes and even showed us videos of heart surgeries and live hearts, in the English Language section of this 267th Samhita, we have Balaji Ramaswamy highlighting the elements of storytelling – corporate or otherwise. Who wants to miss a nice story, especially of a management type that we can use effectively ? MCA has tinkered with the eligibility exam criteria for practising professionals aspiring to be Independent Directors – I am still wary of this whole examination and marks criteria for an ID and how relevant it is for such a role. Well, whether we like it or not, there are rules in place which will continue to ‘evolve’ so to say. Apart from this do download the MCA released FAQs on CSR to guide you in meeting CSR obligations. It will be worthwhile to also access https://www.icsi.edu/media/webmodules/Guidance_Note_on_CSR_Final.pdf, an ICSI publication which deals with CSR issues extensively. For any previous issues of Samhita and the readers’ feedback, please visit https://sharadasc.com/resource-center/.