On violations management: Lessons from aviation

Abstract

We would like to congratulate Cox et al. for their study concerning the differentiation of confirmed and potential major trauma using pre-hospital trauma triage criteria. 4 Cox S. Smith K. Currell A. et al. Differentiation of confirmed major trauma and potential major trauma patients using pre-hospital triage criteria. Injury. 2010; (doi:10.1016/j.injury.2010.03.035) Google Scholar We were very impressed by the fact that paramedics predominantly exercised “considerable discretion” in the application of the triage criteria in the field. In other words, paramedics had conscious failure to adhere to current procedures of triage, which correspond to the definition of violations: deliberate deviations from standard instructions. The propensity of medical community to define the violations as an individual breach of standards reflects a linear logic in which the team member is seen to have wilfully and purposefully chosen not to follow the rules. As Reason suggests, this is a trait of “vulnerable system syndrome” in which immediate causes of individual action are examined to the exclusion of broader questions of underlying conditions that produce migration of practices. 7 Reason J.T. Carthey J. de Leval M.R. Diagnosing “vulnerable system syndrome”: an essential prerequisite to effective risk management. Qual Health Care. 2001; 10: 21-25 Google Scholar But in the Cox et al. work, the violations were apparently accepted by the management of the Ambulance Victoria and trauma centers. 4 Cox S. Smith K. Currell A. et al. Differentiation of confirmed major trauma and potential major trauma patients using pre-hospital triage criteria. Injury. 2010; (doi:10.1016/j.injury.2010.03.035) Google Scholar This illustrates the piece of evidence that violations may need to be explained both by individual drive and wider social, managerial and organizational processes. A better understanding of these factors is the primary step in challenging the persistence of insecure violations.