"Risky Business"

If you were living in the 1980's, or even shortly thereafter, chances are that when you hear the phrase Risky Business, you think about the 1983 hit movie starring Tom Cruise and Rebecca De Mornay.  You probably also think of the iconic scene of Tom Cruise, as a young actor, dancing in his underwear and shades singing Bob Seger's song, "Old Time Rock-n-Roll."

Well, when I think of the phrase Risky Business, I think of...okay, I think of the Tom Cruise movie too.  But I also think of something completely different than 1980's pop culture.  I think of the Risky Business conferences, a series of conferences whose sole purpose are to share experiences and ideas from different high-risk industries, all with the goal of improving safety and outcomes in the health care industry.  The conferences were started by two pediatric critical care specialists named Allan Goldman and Peter Laussen and a British Airways pilot named Guy Hirst.  Many of these conferences are held in London, England.  I had the distinct pleasure of attending one of these conferences a few years ago.  It was truly one of the highlights of my career up to that point - as one of the invited speakers at a joint pediatric patient safety conference held at the same time, I was able to attend the Ceremony of the Keys at the Tower of London.  Every night for the past several centuries, the Chief Yeoman Warder of the Queen's Royal Guard by soldiers as he locks up the fortress.  It was simply amazing!

One of the featured speakers at the conference that I attended was a West Point graduate, Army veteran, and Harvard Business School professor named Scott Snook.  Dr. Snook conducted a half-day session that was essentially a detailed After Action Review of a friendly fire incident involving U.S. military forces during Operation Provide Comfort in Northern Iraq on April 14, 1994.  I believe Professor Snook used the case as his doctoral thesis and later wrote about the incident in an excellent book, called Friendly Fire.  I simply can't recommend the book enough!  Dr. Snook's talk was mesmerizing (I've since tried to get him to come to my institution to present an abbreviated version, but for a number of reasons we've not been able to arrange it), and his book was just as great!

Basically, two U.S. Air Force F-15 fighter jets accidentally shot down two U.S. Army Black Hawk helicopters, killing all 26 peacekeepers aboard.  Dr. Snook used his experience as a former U.S. Army officer (who incidentally was a victim of a friendly fire incident himself) and leading authority on organizational behavior to analyze the incident from an individual, group, and organizational level.  Clearly the lack of coordination between two different military services helped create the conditions that led to the incident.  However, Dr. Snook also found widespread evidence of something he calls "practical drift", the slow, steady uncoupling of practice from written procedure.  His conclusions were both mindboggling and disturbing.  The incident itself was an example of what we have come to call a "normal accident" occurring in a high reliability organization.

The parallels in health care are easy to recognize.  If you don't believe me, just ask any patient who has ever been in the hospital and has had more than one subspecialty participating in his or her care.  Hospitals today are great examples of fragmented, uncoordinated care.  "Practical drift" is more than just a theory in health care, it is one of the most common phenomena that you will see.  "Friendly Fire" is really a fabulous book.  If the purpose of the Risky Business conferences are to share experiences and learning from other industries outside health care, then I would say, "Mission Accomplished."  Read the book.  And if you ever get the opportunity to attend a Risky Business conference, do it!