Surgical checklists

Checklists save lives! A major new study in the journal Annals of Surgery shows a 22% reduction in post-surgical deaths when a simple WHO 19-item checklist was used. It wasn’t a true random experiment, but the clear results are still impressive. “Safety checklists are not a piece of paper that somehow magically protect patients, but rather they are a tool to help change practice, to foster a specific type of behavior in communication, to change implicit communication to explicit in order to create a culture where speaking up is permitted and encouraged and to create an environment where information is shared between all … Continue reading Surgical checklists

Roger Cruickshank on the perfect flight

Roger Cruickshank is a front-line RAF Typhoon pilot. The Queen’s version of Top Gun‘s ‘best of the best, tip of the spear’. He has intercepted 22 different Russian aircraft, including the Tu-95 Bear, Tu-160 Blackjack, Il-78 Midas, Su-34 Fullback, Mig-31 Foxhound and An-26 Curl. Before this posting he was a RAF flight instructor and Olympic skier. So when he talks about making mistakes and perfect flights, we might all learn something. Turns out, he’s not perfect. But he knows it. And he knows how to keep getting closer. This quote is from the (excellent) aerospace podcast Xtended, episode 65: I’m not anywhere where I … Continue reading Roger Cruickshank on the perfect flight

If an error is possible, someone will make it

“If an error is possible, someone will make it. The designer must assume that all possible errors will occur and design so as to minimize the chance of the error in the first place, or its effects once it gets made. Errors should be easy to detect, they should have minimal consequences, and, if possible, their effects should be reversible.” Donald A. Norman, The Psychology of Everyday Things, 1988. Pilot error in many cases can also be described as design error. As pilots, not designers, we should be aware of cockpit actions that are NOT easy to detect, do NOT … Continue reading If an error is possible, someone will make it