I had built up to this day for several months and had made countless trips to the range to practice for what I was attempting. I made myself comfortable behind a bolt action rifle resting on a bench and looked through the scope. What came into view was a piece of steel painted white located approximately 1000 yards away. This would be my first attempt at this distance. I was aiming at a piece of steel about the size of a stop sign, but even under magnification looked small at this distance. I carefully placed a hand-loaded, match-grade round into the rifle and closed the chamber. I adjusted the elevation on my scope, in this case, 34 minutes of angle (MOA). This was based upon data collected from previous shots at shorter distances. At this distance, the current input would mean a straight line out of the barrel would land about 28’above the target! I made a comparable, albeit much less adjustment for wind. This was due to sheltered areas along the path of the bullet and relatively light wind on this day.
I moved the safety to fire and slowly but evenly increased pressure on the trigger until it reached about 2.5lbs at which time the hammer released and struck the primer initiating a reaction that ignited the powder in the case. This controlled “explosion” rapidly built pressure behind the bullet propelling it out of the barrel at about 2,600 feet per second. From the moment this round left the barrel, it was subject to a constant force that cannot be eliminated, gravity. This force would cause the bullet to fall throughout its entire flight, accelerating toward the earth at 9.8 meters per second squared. The time that gravity acted on the bullet would also increase as it slowed down during its flight. This was the reason the actual point of aim needed to be so much higher than the intended place for the bullet to strike about 28’ above the target! I made a comparable, albeit much less adjustment for wind. This was due to sheltered areas along the path of the bullet and relatively light wind on this day.
I watched and waited, a very short time after firing I saw a “splash” against the steel target. A short time after that, I heard a ring from the bullet impacting the steel as the sound finally made it the distance back to my ear. This reinforced to me that multiple calculations were correct, and I was quite elated! There was a very little reflection or thought about the technique that led to the successful hit. I placed another round into the weapon, intending to repeat the process. This time, I saw no splash and heard no ring. I immediately began to think about what could have gone wrong. Did I jerk the trigger, was my platform not stable, had the wind shifted, was my first shot just luck? Virtually no reflection occurred after the first shot, but in-depth reflection began when the second shot missed. We have the same problem in medicine and the systems we use.
The fact that we are all human means that we are all capable of, and likely to make errors. In the above example, I think we can equate human factors to gravity, known and often increasing as time progresses in complex resuscitations. The wind and many other factors such as bullet weight, velocities, etc. make up the balance of patient inputs and environmental/equipment considerations during these events. I think that all too often we equate successful, safe operations with those that have little to no error. We must remember that error exists in success and failure alike. It is successful systems that build in a response to errors, strive for limited errors, and diminishing the consequence of those errors.
Safety is defined as being protected from or unlikely to cause danger, risk, or injury. I argue that in order to do this we must allow for error. It is in situations where things don’t go just as we would like that the most reflection occurs. That moment that we feel we made an “error”. An error is simply defined as the state or condition of being wrong in conduct or judgment. It is in this state where we have the greatest capacity for change or becoming less likely to cause danger, risk, or injury. We become safer through error! It is an error without significant consequence that we should be most interested in. This is where we can identify issues with systems or processes before a significant consequence is experienced.
The primary corrective strategy we must embrace is that assigning blame whether intrinsic or extrinsic, is wasted time and energy. It is not possible to blame and improve at the same time. This is vital for people at all levels to embrace, but particularly in management/leadership. A just culture where people feel empowered to come forward with errors is vital to safe and secure operations. Errors are going to occur, and it is our knowledge of them that allows system and process modification to prevent similar errors moving forward. Think of it like this, if you are a parent meeting your child’s first “boyfriend or girlfriend”, it is your response that often dictates whether you meet the next one or not.
Better “hot wash” or post-incident review of those events we deem as largely successful is the other area I believe we have a capacity for change. There is always something that we can take from any degree of success. This is particularly true if the above culture exists and providers of all levels feel free to come forward with opportunities that may seem insignificant or having little effect. This valuable discussion can aid others in understanding how we succeeded and potentially improve their own intuitive decision-making abilities. It is here where we can realize what we thought was a great success was fraught with error absent of significant consequence, this time! Please keep this in mind the next time you get ready to beat your chest and display bravado following an airway first-pass success. It is this environment coupled with a poor culture that discourages growth without adverse events.
Please remember that we are all human and while on this earth subject to gravity, just as my bullet was. The fact we will experience physical and cognitive changes under pressure must be just as widely accepted. It is our recognition of this and how we embrace innate human factors with resultant errors that will drive peak performance. If you are wondering, I was able to successfully repeat my first shot one time that day. Perhaps it was just luck, but either way, I have plenty to reflect upon and some ammo to go reload.
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