Only 20% of surgeons would like to use a checklist in their operations…

checklists human factors Nov 08, 2018
…but 94% would like one used in an operation on themselves…!
 
Atul Gawande gave four presentations before Christmas as the 2014 Reith Lectures’ presenter (BBC iPlayer downloads and transcripts can be downloaded from here).
 
During these presentations, he highlighted ways in which the healthcare and medical industries could develop their safety further, but he also recognised that we are all human, fallible and therefore there was a limit to what could be achieved and, consequently we needed to recognise this when judging adverse outcomes.  The same situation needs to be recognised within sports diving where we are undertaking an activity (of our choice) which has an inherent risk of fatality as we are in a hostile, non-life sustaining environment if something serious goes wrong.
 
His second presentation specifically looked at how better systems could improve safety, and radically reduce the mistakes and errors made, and improve...
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Are you a good enough diver?

Uncategorized Oct 07, 2018

What does ‘good enough’ mean? If you think about it, ‘Good’ is a relative term because, by definition, there must something or many things which aren’t good and you are making a judgement against your perception of good.

The term ‘Doing It Right’ or DIR attracted significant criticism in the 1990s and early 2000s because of a logical fallacy we often use to view the world in binary options. If you aren’t doing it ‘Right’ then you must have been ‘Doing It Wrong’. 

However, once we grow up from such a childish view, we realise the world is far more complex than that and such binary attributions are not valid nor are they helpful when it comes to learning or improving relationships. There is always a compromise but as long as the compromise is informed and the trade-offs understood, then why not use it? 

Unfortunately, the same binary attributions are often used for ‘safe’ in diving....

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'Choices': Guaranteed small loss or a probable larger loss, injury or fatality?

You have been blown-out for 4 weekends in a row and you now have an opportunity to dive this weekend as the weather is fabulous and the visibility has been reported as 10m+. However, you aren’t due to dive for another four weeks for a variety of reasons. Just as you getting your gear ready to put on, you notice that you have a malfunction with your gear, something manageable but will cause you additional workload and reduce your margin of safety on the dive. This is a failure you wouldn’t normally accept because you get to dive lots. If you don’t dive, your buddy will have to sit out too as there isn’t anybody else to dive with them at such short notice. What do you do?

At this point, you are managing uncertainty not a risk because the numbers are not calculable. You decide to dive and nothing adverse happens and you have an awesome dive.

Are you reflective of your management of uncertainty? Did you think it was ‘good’?

But what if two or three...

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Risk of diving fatality is 1:200 000. However, you cannot be a fraction of dead…!

Uncategorized Sep 10, 2018

The risk of a fatality in diving has been stated as

16.4:100 000 divers (DAN Figures)
14.4:100 000 divers (BSAC Figures)
0.48:100 000 dives (DAN Figures)
0.54:100 000 dives (BSAC member dives)
1.03:100 000 dives (non-BSAC dives)
Fatalities Conference Proceedings 

but what does that mean? I can tell you that it means nothing to most people because we don’t deal with risk in the real world like that. For a start, numbers don’t have the same emotional relevance as stories, and as such, they don’t stay in our heads that long. Furthermore, most decisions are informed by emotion and not logic and the following is a classic example of the apparent irrationality of perceived risk.

A colleague of mine did a 'Discover Scuba Diving'-type dive while on a cruise to the Caribbean. Her only diving experience prior to getting into the ocean was in the swimming pool of the cruise liner she was on. Her first dive was to 30m/100ft on a deep wall in the Caribbean which was advertised...

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Dive safety leads to nothingness...and nothingness is unemotive!

How safe are you when you dive and how do you measure safety? Think about the following story and how safe the situation was...

Six divers had decided to undertake a 30m dive from a RHIB. John and Dave were diving as a team with their local university dive club and had over 2000 dives between them. Graham was relatively newly trained as a marshal and had not worked with Brian before. On the dive boat, there were two new divers to the club, Gail and Mark. Both Gail and Mark had successfully completed a check-out dive & dry suit familiarisation course with another instructor in the club, and they were already certified for 40m diving. Graham was keen to do a drift dive in 32m of water. Brian, the cox, was somewhat worried about the conditions as there seemed to be waves forming. However, as long as all divers were certified to 30m diving and effective at getting into the water and back onto the RHIB, he was happy that the risk was acceptable. To allow the Cox and Marshall to...

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Why ‘everyone is responsible for their own risk-based decisions’ isn’t the right approach to take to improve diving safety.

A diver qualified in the summer of 1999 while on holiday in Greece. His final dive on his PADI Open Water course was to 25m, obviously beyond the standards of this course. The instructor told him to write 18m in his logbook as they were only supposed to go to 18m. The diver didn’t know this during the dive so didn’t question the depth they dived to. Nor did they know that there was a way of providing feedback to the agency for breach of standards. In March 2005, the diver went to Cape Town with work and there was an opportunity to dive at Gansbaai so he took his OW card with him. He hadn’t dived since his OW course in 1999. There was no checking of cert cards when they got there, nor was there a skills dive to ensure everything was ok. The diver and 3 of his buddies completed a 45min 10m dive from a RHIB with no problems.

One month later the diver was in San Diego, again with work, and wanted to go diving. He had decided that one of the most important things he...

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Cognitive Dissonance - Why you are right and I am wrong...Or are you?

"A man with a conviction is a hard man to change. Tell him you disagree and he turns away. Show him facts or figures and he questions your sources. Appeal to logic and he fails to see your point." -  Leon Festinger

Cognitive Dissonance has been defined as the psychological pain of accepting facts which are counter to our views which then prevents an open and rational cycle of improvement.

Recently I re-read Black Box Thinking by Matthew Syed (a book I’d thoroughly recommend). The book uses aviation safety as the premise for improving patient safety by looking at the ways in which data has improved the former - the data from aircraft black boxes and cockpit voice recorders showed investigators what the pilots saw and experienced and how it could have made sense to them at the time, despite what hindsight bias and outcome bias would them to believe. Furthermore, data from the aircraft systems would allow reconstructions to take place in the simulator to see lessons...

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Just another brick in (under) the wall...taking action

If you want to do something new which improves your safety or performance, how committed are you? If you see something shiny, how easy is it to buy that compared to making a change to your habits or behaviours? Which is likely to have a greater effect on your diving?

Three weeks ago I met Isabel, a business coach specialising in branding and marketing, with a view to working with her. She had been recommended to me as a coach who has the knack of pulling coherent ideas from the free-flowing discussions and coming up with a clear message regarding an offer, branding and identity.

As Isabel and I sat there waiting for our coffee to cool down and talking about the future, she asked me a really important question. “On a scale of 1-10, how committed are you to making a difference to your business so that you can grow and get to where you want to be.” 

I said "9". I also added that given the time I put into developing human factors and non-technical skills...

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'Entirely Predictable' vs 'Managing Uncertainty': How many rolls on the dice?

decision making risk Jul 22, 2018

A couple of social media posts about diving incidents and near misses have triggered this blog because the term ‘entirely predictable outcome’ has been used to highlight that someone shouldn’t have done what they did because it was obvious that it would end up with an injury or death. The problem is that such statements, as they applied to those particular situations, are false, even when the commentators are biased because of hindsight.

To explore this, let's look at the dictionary definitions of ‘entirely predictable’. Entirely means ‘completely’ or ‘to the full extent’ and predictable means ‘always behaving or occurring in the same way as expected’. So entirely predictable means that on 100% of occasions the outcome would be as it was experienced in the particular occasions. If this was true, people would not do things which ended up with them injured or dead (unless they truly had suicidal tendencies, and those...

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“The standard you walk past is the standard you accept”

just culture reporting Jun 18, 2018

A few days ago a post was made on Facebook outlining the process by which a PADI student or professional could raise a QA claim against a professional or facility. One of the comments written below was 'Snitch!' This frustrated me because my perception based on 26 years in the RAF is that if standards are not being adhered to, then something needs to be said to bring those involved back up to what is expected. The reason is that the standards are there for the safety and performance of all involved. Of course, deviations occurred while I was serving, we made mistakes and undertook at-risk behaviours - we were human after all! Most of the time they were debriefed to find out not just why they happened, but also because innovation can only exist when deviation happens and if that deviation has led to an innovation, then let's learn from it and make what we have better. Feedback worked because, fundamentally, it was normal and expected. Aircrew were used to giving and receiving...

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