Black Box Thinking

I loved Bounce so have been anticipating this with some excitement. Matthew Syed undertakes all the research so we can just sit back and learn it all by reading his books.

Bounce took the idea that just about anyone can be good at pretty much anything, it just takes practice. My take on Black Box Thinking puts out the idea that if more of us learnt from mistakes, the world would be a safer, better place.

Having been to the authors promotional event at the local Waterstones, I was warned about the heart-breaking opening story about Elaine Bromiley, a healthy lady dying on the operating table during a routine operation.

The author asks who in the audience was interested in sports, education or teaching? Whilst I have an interest in all three, my category – business – wasn’t mentioned. Being a fan-girl, I just turned up and bought the book on the day. There are always a few avid readers who go to these things armed with questions. I’m not one of those.

This is how I learnt what this book was about and it is indeed entirely relevant to my world. 

A good summary of Black Box Thinking is that whereas in the aviation industry, they immediately look for evidence as to why the accident happened and how they can do better next time, saving untold lives, the medical profession, in the main fails to learn from it's mistakes.

In an American study, a million people are said to be injured by hospital errors. 120,000 each year. A later 2013 study puts figure at 400,000. This is the equivalent of a 9/11 catastrophe happening every 2 months.

We wouldn’t tolerate this in any other area of preventable harm.

In the UK, 34,000 are killed due to human error.

In aviation, independent investigators immediately find out what went wrong, how to fix it and then share that openly with the world. Every pilot has access to the data. Syed says soon we won't need black box as all the info will have been already transmitted to a central database while the accident is happening. 

Learn from the mistakes of others. You can't live long enough to make them all yourself.

Sullenberger, who landed the plane in the Hudson River (while I was living in just up the road in New York, incidentally) credited all the lessons learnt from aviation deaths to his safe landing. 

The Toyota Production System (TPS) was put in place so if anyone on the car production line had a problem, they pull a cord which halts production. The error is assessed, lessons learnt and the system adapted. Try putting that into health service where mistakes are frowned upon & people are too scared to report their seniors, which is why the preventable death in the opening paragraph occurred.

30-60000 deaths in USA are due to central line infections (catheter placement) 

A healthcare organisation in America, Virginia Mason tried to put into place Patient Safety Alerts in 2002 but no one would report the errors. After the next death,  their boss issued a public, heartfelt apology. Complaints started coming in and it’s now one of the safest hospitals in the world and they saved 75% in insurance premiums too.

Pronovost (who wrote Safe Patients, Smart Hospitals) instituted 5 point check list and saved 1500 lives. Plus c $100m over 18 months in Michigan.

To really bring it home, I learn it took 264 years to put a preventative measure for scurvy in place.

So that others may learn, and even more may live - Martin Bromiley, husband of Elaine and campaigner.

More BlackBoxThinking business learnings here. In the meantime, if you have any thoughts to share, please contact me via @RickieWrites