Assessing Risk on a Plane — As You Fly It

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May 21, 2021

By Stephanie Schorow for the Global Mass Vaccination Site Collaborative

The question was put to the Zoom audience of team members who run mass vaccination sites: Did you proactively do a risk assessment ahead of time to ensure safety and reliability?

Pause. Then Becky Fox, MSN, RN-BC, of Atrium Health, said, “No. We had six days to get ready, and one of those days was a holiday.”

Others nodded. Said Captain Dirk A. Warren, M.D., the Surgeon General of Joint Task Force Civil Support, “We were building the plane in flight.”

But this was exactly the point of Karen Fiumara, Executive Director of Patient Safety at Brigham and Women’s Hospital, who did a presentation on risk management for the collaborative on May 21. Health managers have to focus on both system reliability and human reliability, she said. Distraction, experience, and implicit bias are all part of that human performance. “We consider a system effective if the system manages a risk,” she said. However, “resiliency does not mean unbreakable.”

In a lively back-and-forth exchange, members of the group spoke honestly about the challenges of setting up a system “in flight” and the inevitable incidents that occurred along the way. These included unprepped syringes and unforeseen environmental problems, such as an elderly person who failed to negotiate an escalator.

“If you think you did have a perfect scenario, you probably don’t realize your errors,” said Eric Goralnick, MD, MS, Associate Faculty, Ariadne Labs and Principal Investigator of the collaborative.

Others were positive. Said Will Roy, Federal Coordinating officer with FEMA region 1, in the Zoom chat: “From my personal experience in visiting VAX sites the feedback from the guests has been nothing but positive — ‘flowed like a well-oiled machine’ was the majority of the comments.”

“We scaled up as we learned along the way,” said Randy Van Straten of Bellin Health. “We also learned to partner better with community assets.”

Fiumara stressed that the “cultural experiment” of the pandemic could be used to improve safety in health systems. Her points included:

  • Examine errors. Is it the person or the system? Most of the time it’s the system.
  • There are two reasons why humans follow rules. One: You’re afraid you are going to get caught if you do not follow rules. (You drive differently when a police car is behind you.) Two: You appreciate the risk of not following the rules.
  • You cannot punish somebody into better task performance.
  • Avoid attributing vaccine hesitancy to specific groups. Rather, emphasize that there is a “well-earned distrust of the medical community.” Roy noted that you can really only say there is hesitation when you have the supply and the opportunity for vaccination, which was not the case. “We shot ourselves in the foot right out of the gate,” he said.
  • Humans are only vigilant to a certain level for a certain period of time. People have to be acutely attuned to risk to remain aware of it.

The Global Mass Vaccination Site Collaborative was launched as a way for stakeholders directing vaccination campaigns around the world to come together and learn from each other’s efforts. This blog series was created to record and share the learning and insights gained from this collaboration. Read blogs from our previous meetings here.