One of the most moving speeches I have read is one given by Don Berwick, the head of the Institute for Healthcare Improvement, at his 1999 annual symposium. It was entitled Escape Fire, and it drew lessons from a tragic fire at Mann Gulch in Montana.
Here is a summary from the link above: "When fire surrounded more than a dozen firefighters on the hillside, their leader had an unusual idea for survival. He burned an area of pasture around him and lay down in the dead grass in hopes the fire would pass over him (an escape fire). His team found the method too risky and refused to join him. Most of them perished in the inferno, while their leader survived. Dr. Berwick's message to health care professionals is that rejecting innovative ideas will have grave consequences on the industry."
I had occasion recently to visit the smokejumpers headquarters in Missoula, Montana. You would be hard-pressed to imagine a more dedicated group of people, who risk their lives by parachuting into remote areas to snuff out forest fires. As you can imagine, too, this is a group that pays a lot of attention to safety and that has a terrific record on that front. By any measure, we in health care have a lot to learn from them.
Imagine my surprise then, when I conversed with one of the crew and asked a simple question based a picture in the wall of the HQ. It showed a jumper leaving a plane in a "sitting" position, legs out front. I simply asked, "Is that the expected body position?" The man I asked said that it was a generally good position in that the aerodynamics tended to twist the person's body in the right direction to avoid tangling up in the airplane or other problems.
But then he said that for a tall person, the position could be problematic in that some percentage of the time, the aerodynamics would actually twist you in the wrong way, leaving the jumper a bit disoriented and his parachute apparatus in an uncomfortable position. So, he said, he learned to bend his legs up under his butt and take a more cannonball position leaving the plane. This would avoid the unexpected twist after leaving the airplane. Later, in talking with other jumpers, he learned that some of them did the same thing. So, there was an informal "rule of thumb" that was in play for some of the jumpers for many years.
Here was the interesting punch line: Notwithstanding the long-standing existence of this helpful informal knowledge, it has only been recently that this alternate form of jumping position was formally included in the smokejumpers' training curriculum.
The lesson for the rest of us: If an absolutely superb, tight-knit, highly focused, and disciplined organization like the smokejumpers occasionally experiences informal work-arounds to safety and quality issues -- with inherent delays in systemic education and improvement -- imagine the degree to which this occurs in complicated places like hospitals.