Kathy Duncan, RN, IHI Faculty
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Learning Objectives: At the end of this activity, you will be able to:
List three principles of reliable systems.
Explain how the Central Florida Zoo uses these three principles in protecting staff from venomous snakes.
Discuss how the zoo’s safety system can be applied to health care.
Description: Health care isn’t the only industry that’s working to protect people in dangerous conditions. Each year at the IHI National Forum, IHI faculty lead excursions to organizations outside of health care to learn about how they do their work. Kathy Duncan, RN, IHI Faculty, leads a trip to the Central Florida Zoo, which has one of North America’s largest collections of venomous snakes. In this video, Duncan goes behind the scenes to learn about the staff’s safety procedures for handling snakes when they need to be moved from their enclosures.
Discussion Questions:
- The video lists three principles of reliable design and how the zoo applies them in the setting of venomous snakes. How have you seen the same principles applied elsewhere? List at least one example for each principle, from health care or another hazardous setting.
- Reptile Keeper Michele Hoffman says that teamwork and a culture of transparency and trust is important to protecting safety. How do you think teamwork promotes each of the principles of reliable design?
- What would happen if the zoo waited to redesign its systems until an actual failure — not just the possibility of a failure — had occurred? In your experience, are health systems more often proactive or reactive when it comes to addressing safety issues?
- In patient safety, defects in the design of a system are called “latent error” — errors waiting to happen. (Learn more about latent error in PS 101: Fundamentals of Patient Safety.) Can you think of an example of a latent error from the zoo that staff took action to address? Have you seen examples of latent error in health care?
