By Yoel Donchin
I met Professor Daniel Gopher just before the Passover Seder, which took place at my brother’s home in Urbana, Illinois. I asked him: “What are you doing in life?” His response was: “I investigate why workers fall from a height, why carpenters lose their fingers.” I had no idea what kind of scientist he was. As an anesthesiologist, I did not perceive psychology as evidence-based or scientific (even though my brother was chair of the psychology department at the university). I told Danny that I had a problem. At my ICU at the hospital, we encountered on an almost daily basis that teams make mistakes and errors, sometimes by nurses and sometimes by physicians. Back in Israel, I invited the Technion team from the “Center for Human Factors and Safety at Work”, where Danny was the head of the centre, to visit our operating room and intensive care unit. The team arrived one day, looked around, made notes and photos and interviewed staff. At the end of this tour, they stated: “We have visited factories and power plants and assembly lines, but chaos like that, we have never seen!” This was the start of my understanding that we need the help of “human factors engineers.”
We applied and received a substantial grant, and we conducted the first study in 1986. Human factors students observed the ICU 24 hours a day and recorded their notes (on paper!) They were determining what an “accident” was. Simultaneously, a special form was designed for medical personnel to report and describe events that they have diagnosed as a failure or a near-miss incident. We submitted an abstract to the Human Factors society in Colorado (1989, Fig 1) and it was accepted, but the organizer did not know what section to place it in. The organizer created a “POTPOURRI” section, as healthcare was not one of the domains studied at that time. I was the only physician at that annual meeting of Human Factors. The paper topic was “The nature and causes of human error in the ICU” A year and a half later, I received an invitation to speak before a group at The Ohio State University on a letter co-signed by Richard Cook and David Woods. I kept showing the invitation to the university, with a date correction. (Fig 2) After the lecture, Richard and David took me to the Barnes & Noble campus bookstore and for an honorarium gifted me with the book titled “Human Error”. In this book, James Reason introduced the Swiss cheese model of accidents. Richard signed the book. (Fig 3)
Then my life changed.
The story of the paper after the conference is interesting enough as we decided to send it to the New England Journal of Medicine, where it was rejected because the journal “was not interested in medical error” and only accepted scientific work. (Fig 4) The rejection included twelve pages of recommended revisions and was recommended to send it to the Journal of Critical Care Medicine. We did this immediately without making a single change. A week later, I got a message (fig 5) asking “Why you did not make the changes recommended by the NEJM editor?” Finally, it was published and got me the ticket to Annenberg 1. I would not be surprised if Richard arranged the invitation to attend, as I think that I was the only anesthesiologist who attended among a small number of other physicians, including Lucian Leape.
During my visits to learn from and consult with Richard, he took me to his apartment, which consisted of two rooms in a basement. There I stayed and ate food he prepared for me while lecturing and shaping my thinking.
I was so naïve that, with hutzpah, I informed the director general of Hadassah Hospital that I would like to start a safety unit. It took him a few minutes before he agreed. So, for the first time in Israel, a conference with the logo “Avoiding human error in the hospital: mission possible ?!” was planned. Richard agreed to come and give the keynote presentation to this group that is beginning to care about this unknown idea of “safety.” At the end of his unforgettable presentation, he took out his camera and took a picture of the audience from the podium. He said: “You are the safety group in Israel, as you all understand the issue.” (Fig 6 ) He was right!
Every visit to Richard’s Cognitive Technologies Laboratory at the University of Chicago after his transfer from engineering to anesthesiology gave me the energy and new ideas to pursue implementation in Israel. I find that conferences are very expensive, and some are a waste of time, but being with Richard for a few days was truly inspirational. Of course, it was also wonderful to tour the campus, the library, and their unbelievable bookstore. We established a regular video conference between our pediatric intensive care unit and Richard’s laboratory. He inspired me to study human factors and I joined Danny’s department as a graduate student. I left the operating room and started a full-time job at my hospital as a safety “expert.”
Richard and his wife, Karen, visited us in Israel, preparing his talks in our home (fig. 7 and 8) and later touring the holy places, including the Dead sea and of course the old city of Jerusalem (fig 9).
On one of his visits, when Richard stayed in our home, there was a mass casualty event at our hospital. I asked whether he wanted to come to observe with me as the mass casualty victims were on their way to the Emergency Room. His response was: “Sure!” His impressions and reflections on differences in approaches between our hospital and the United States were published in a 2006 book chapter in the book: Resilience Engineering Concepts and Precepts. The chapter starts with “A senior Israeli physician (DY) heard the detonation of the bomb at 07:10 and he drove with one of the authors (RC) to the Hadasah EIin Karem hospital.” (page 210). It is a must-read. While I was at work, Richard didn’t say anything. He met my wife that came later to work at the information centre rather than in her room at the public health department, and he spoke with parents that accompanied their daughter to receive a CT scan. When I read the chapter it was the first time I realized what he had seen. Like the hero of Mouliere, who didn’t know he was speaking prose, I didn’t know that the hospital had great resilience. The door was now opened for me to think differently.
I went with Richard and his family to a restaurant in Chicago. I joined him as he went to see his granddaughter at school (Fig 10, 11). I feel like I’ve lost a relative. A loved one. It has been my honour to be a part of his professional life.
A few months before he passed, I read a Hebrew poem that I felt I needed to share with Richard. Mike O’Connor read it to him when he was having challenges reading small print. I sent it after his death to Karen.
Do the songs soothe the pain?
