When multiple people are involved in complex or even cooperative processes, reduction of error is more likely when solutions are sought at the organizational level rather than the individual one. A systems approach will consider the different factors that affect the process of delivering a product or service to improve the way that each task or job interacts safely and efficiently with the overall operation.
The recognition that health care should look to systems-based approaches to patient safety came in 1999, when the Institute of Medicine released a startling report entitled “To Err is Human: Building a Safer Health Care System.” This was the first major report that concluded that many hospital deaths occurred as a direct result of errors and accidents. The discovery made the medical profession reconsider its standards of practice, especially in light of its motto primum non nocere (first, do no harm), which serves as the basis of the ethical practice of medicine.
Health care’s response to this report was to change the way it examined patient safety. Rather than see medical error as an ad hoc phenomenon, it began to create patient-safety initiatives based on a systems approach to deal with the problem. Of course, with more than 170,000 deaths due to medical error per year, there is still much work to be done.
The classic paradigm of a systems-based approach is the “Swiss cheese” model, where an accident can only occur if there is a path in the system that allows the mistake to pass through multiple checkpoints – similar to passing through the holes in how Swiss cheese slices fit together. The key is to create checks that stop the error from pushing through the process. The result is minimizing the number of errors or accidents that occur.
Systems-based quality improvement balances minimization of risk and increasing redundancies through additional checks and reviews between various steps in a process so that the result is a better and safer product or service that still maintains efficient delivery.
Here is one very simple example of a systems-based technique that could have prevented Halyna Hutchins’s death. Atul Gawande wrote a book, “The Checklist Manifesto: How to Get Things Right,” about the use of checklists by surgical teams and airline pilots to avoid mistakes of ineptitude, i.e. those mistakes that come when people do not make proper use of what they know, rather than acting out of ignorance. The checklist serves to ensure that people actually stop and check. It forces the team not to make hasty and deadly assumptions of risk.
The crew on the “Rust” set would typically check the prop gun, but they reportedly didn’t use a checklist. They didn’t formalize the process. And before Halyna Hutchins was shot, the crew member responsible for overall safety on the set didn’t properly check the gun.
Unlike health care delivery, which is highly structured and regulated, film does not work with groups of licensed professionals interacting along clean lines of responsibility and accountability. Film sets are chaotic places with murky hierarchies, populated by people with a wide range of abilities and overlapping duties.
Production skills develop through apprenticeships, and the industry resembles something like a guild, with both union and non-union employees. Non-union employees are not necessarily less able than those who have joined a union. One can enter the movie production business in a million ways, including nepotism. Prior experience is valued but impartial oversight of such skills is absent.
Though not obvious, movie production and healthcare delivery do, however, have important things in common. Both engage in activities requiring the simultaneous work of many individuals performing a variety of specific tasks that require training. In both fields, improper safety measures can lead to accidental death. While this recognition led to a transformation in healthcare, the film industry has not yet learned this lesson.
Ira Bedzow is the director of the MirYam Institute Project in International Ethics and Leadership in the Center for the Study of Law and Religion at Emory University School of Law. Joel Zivot, M.D., is an anesthesiologist and an associate professor of anesthesiology and surgery at Emory University, and is a senior fellow in the Emory Center for Ethics.