Key Safety Strategies Discussion Guide

Checklists:
• In the air disasters episode, Deadly Distraction, how did they utilize checklists? What worked and what
failed?
• Imagine you are a very busy community pharmacy where you have to check scripts, counsel patients,
give immunizations, check orders all at the same time. You are the only pharmacist and you have 1 other
technician with you.
o What checklists would you utilize? Why those specific checklists?
o What problems do you expect with utilizing these checklists? How do you manage keeping up
with the checklists but also making sure patients are getting their medications in a timely
manner?
• In the hospital, normalization of deviance is a trap that many HCPs can easily fall into, especially after
seeing similar orders every day, with checklists.
o What do you think needs to happen in a hospital (or any healthcare setting) to combat user
fatigue and normalization of deviance?
o If you were Vanderbilt Medical Center, how would you change your checklist to make sure a
medication error like this does not happen again?

Training:
• How do you think the flight crew from air disasters were trained? What were they missing?
• How do you think training differs in each part of the United States? What about the world? How does
this impact a unified vs a diversified practice? What are the pros and cons of this?
• For pharmacists and HCPs in general there is usually a big difference between what is learned and what
is practiced in the field. How do you think we can bridge the gap with what we have learned about
aviation industry?

Sterile Cockpit:
• Identify the distractions in the cockpit from Delta airline crash. Why do you think those distractions were
so impactful in causing the airline crash?
• In an ideal world, we can put up a do not disturb sign up and have no distractions, but in reality this is
not always possible with constant pages, orders coming in, something urgent that comes up. How do
you think we can find a balance between a distraction free environment and putting out fires in a
hospital, community, industry setting?
• Imagine you are an HCP in a surgery room and the surgeon starts playing their favorite playlist.
o What values and drawbacks do you see music playing during a surgery?
o How would you change the music policy (if at all) to incorporate a balance between surgeon
autonomy and creating a distraction free zone?

Key Takeaways:
• Checklists, training, CRM, and sterile cockpit are 4 safety strategies that we must take from the aviation
industry and integrate into healthcare culture to improve patient and medication safety
• We have to start with a cultural change and education in order to implement these strategies
successfully
• It takes a team that works and listens together to be successful in implementing these strategies