Medical Error - Learning from mistakes: Kevin Fong
The information we consume leads us to believe that failure isn’t an option. Stories and movie depictions of characters who avoid the odds at all costs, tell us that failure is unacceptable and should be avoided. We expect elite performance and hyper competence. In medicine, where we are responsible for the lives of our patients, it is easy to understand why we set the bar high for ourselves and somewhat expect ourselves never to fail. The reality is however, that this is all a myth. Any complex system you can observe from around the world has experienced failure. In fact, the biggest lessons usually come from the biggest failures. In healthcare, we work in the ultimate complex system, where nobody is hyper competent and failure will always occur. It is inevitable. According to sociologist Diane Vaughan, wherever science, technology and risk to human life coincide, failure is inevitable. The answer is in finding ways to appropriately deal with failure and to overcome these challenges. So, given that failure is inevitable, is there a better way to fail? How do we fail gracefully? We need to learn to fail and understand that we do so out of a love for our profession. By savings lives and helping others. Our system needs to allow for failure to occur but also to ensure that we fail gracefully. Kevin Fong shares a compelling talk on how to prepare to fail, how to expect failure and most importantly, how to forgive yourself for failing. A talk that Kevin describes as “useful advice for failing at everything.” From DAS SMACC, we hope you enjoy this podcast and we hope that it inspires you to embrace failure in a new light. For more like this, head to our podcast page. #CodaPodcast
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Medical Error - Learning from mistakes: Kevin Fong
- 1. How to Fail Kevin Fong University College London Hospital @kevin_fong
- 2. Part 1 Failure and Complexity
- 3. Thomas Thwaites – The Toaster Project
- 9. Failure Modes Fail Safe Fail Deadly Fail Operational
- 10. Fail Safe
- 11. Fail Deadly
- 12. Fail Deadly
- 13. Fail Operational
- 14. Fail Operational
- 15. Failure Modes Fail Safe Fail Operational Fail Deadly
- 16. Fail Badly
- 17. Is there a better failure mode?
- 18. Part 2 The Mythology of Failure
- 21. “ In the face of overwhelming odds I am left with only one option …
- 22. “ In the face of overwhelming odds I am left with only one option … I’m gonna have to science the shit out of this ”
- 23. Competence Porn
- 24. The High Performing Psychopath
- 26. SERE course for US Special Operations Soldiers
- 28. Part 3 How to Fail
- 29. Reliability is more important than Performance
- 30. Reliability is more important than Performance
- 36. Graceful Failure “ Graceful degradation is the ability of a system to maintain most, if not all, of its function in the face of failure ”
- 41. “I think health care is more about love than about most other things. If there isn't at the core of this two human beings who have agreed to be in a relationship where one is trying to help relieve the suffering of another, which is love, you can't get to the right answer here.”
- 42. “I think health care is more about love than about most other things. If there isn't at the core of this two human beings who have agreed to be in a relationship where one is trying to help relieve the suffering of another, which is love, you can't get to the right answer here.” Don Berwick Institute for Health Improvement
- 43. “ Forgiveness is me giving up my right to hurt you for hurting me. Forgiveness is the final act of love ”
- 44. “ Forgiveness is me giving up my right to hurt you for hurting me. Forgiveness is the final act of love ” Beyonce Knowles Singer, Philosopher
- 45. “ Forgiveness is the final form of love ” Reinhold Niebuhr Theologian, Ethicist
- 46. How to Fail Kevin Fong University College London Hospital @kevin_fong
Editor's Notes
- Thomas Thwaites
- £1187.24p in materials. C.f. £24 for one that works and doesn’t kill you.
- http://www.cpushack.com/space-craft-cpu.html Curiosity rover uses a RAD6000 with a 25MHz maximum clock speed. Shake and bake procedures – which mean that the 486 processors that ran space shuttle weren’t the same ones in your desktop https://www.geek.com/news/hubbles-cpu-is-not-your-fathers-486-1371049/ BAE RAD6000 (25MHz Max): This is a radiation hardened version of the IBM RS/6000 Processor (RSC). Cost is around $200,000-$300,000 https://history.nasa.gov/computers/Ch4-3.html
- NASA’s GPC for the space shuttle. Radiation hardened, multi-redundant, 5 processors. https://www.nasa.gov/mission_pages/shuttle/flyout/flyfeature_shuttlecomputers.html “reliability means more than performance” “which is the same as saying the worst doctor on the worst day and still do the job.” A software change typically goes through about nine months of in-house simulator testing and then another six months of testing in a unique NASA lab before it is accepted for flight. The results of the strenuous testing regimen? Well, it has been 24 years since the last time a software problem required an on-orbit fix during a mission. In the last 12 years, only three software errors have appeared during a flight. But perhaps the most meaningful statistic is that a software error has never endangered the crew, shuttle or a mission's success.
- Language about “never events”
- Charles Morgan slide from Seal SERE course. Search, Evasion, Resistance and Escape school
- You work in a world where reliability is more important than performance. It is the reproducibility of the system that allows you to make a difference. It is the difference between eilte arts performance and olympic sports people and a medical intervention that can save lives. It is why our multi-centre, multi-country, multi-year trials invearbily yield negative results – because they are generally about surrogate markers of elite performance than they are about an intervention that can be reliably delivered. NASA’s GPC for the space shuttle. Radiation hardened, multi-redundant, 5 processors. https://www.nasa.gov/mission_pages/shuttle/flyout/flyfeature_shuttlecomputers.html “reliability means more than performance” “which is the same as saying the worst doctor on the worst day and still do the job.” A software change typically goes through about nine months of in-house simulator testing and then another six months of testing in a unique NASA lab before it is accepted for flight. The results of the strenuous testing regimen? Well, it has been 24 years since the last time a software problem required an on-orbit fix during a mission. In the last 12 years, only three software errors have appeared during a flight. But perhaps the most meaningful statistic is that a software error has never endangered the crew, shuttle or a mission's success.
- In a complex world, reliability is more important than performance. The more complex the system the harder you have to work to engineer reliability and the more inevitable failure becomes. £1187.24p in materials. C.f. £24 for one that works and doesn’t kill you.
- 1628
- Capuccini – case daily mail
- https://en.wikipedia.org/wiki/Reinhold_Niebuhr