Save Me!

Added on Oct 27, 2015

Everybody needs to be saved sometime. Sunandha Kumariratana needed to be saved, and there was no one to save her. Sunandha Kumariratana was a queen of Thailand. In 1880, on her way to the summer palace traveling by picnic boat towed by royal barge, the queen was thrown into the river when her boat capsized. She could not swim. And even though she called for help – no one came to her aid. An ancient and stringent Thai law forbid any commoner from touching a member of the royal family. The punishment for doing so was immediate death. All of her servants watched her drown.

Patient Safety

Healthcare providers and care givers also need to be saved sometimes. Will there be anyone there to save us? Steep authority gradients and large power distances keep people from saving us. That is our modern version of the ancient and stringent Thai law. What could we do - what should we do – to flatten authority gradient and reduce power distance?

Historically patient safety has been thought to be a competency of the individual. They were either safe or unsafe. With today’s complex systems, safety is an emergent property of the system. We rely on each other to think together as a team. John Nance – the aviation safety expert – said of Tenerife, “one man made a mistake and that mistake stuck.”

We all know that we will make mistakes – don’t let those mistakes stick. Instead, save me.

For tomorrow – please read the literature. Read about authority gradient, power distance, psychological safety, mutual respect, and teamwork.

For today, read these simple insights:

  • 1. For those with less power and authority: follow the great American philosopher – David Letterman – “pretending to be courageous is just as good as the real thing.” After all, if we believed in Santa Claus until we were eight, we can believe in our self for the next two minutes.

  • 2. For those with more power and authority: follow the advice of Dr Gail Thurmond – vice president of clinical effectiveness for Methodist Le Bonheur Healthcare in Memphis, TN. A sign in her office is inset as an image to the right.

  • 3. For those of us who are safety leaders: follow this advice - “what you permit, you promote” – source unknown, although I believe the expression comes from IHI.