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Learning from failure

As part of a major national project on innovation, Scientell has examined the contribution that learning from error and failure can make to innovation and progress. This is part of our work with the Australian Council of Learned Academies (ACOLA) to synthesise a wealth of information into a book on securing Australia’s future. The following is a sad example of failure.

On 29 March 2005, 37-year-old Elaine Bromiley entered a British hospital to undergo routine surgery to clear her sinuses. The mother of two was otherwise healthy.

Problems occurred immediately the anaesthetic was supplied. With no warning, Elaine’s oxygen levels plunged. Her airway was blocked – a most unusual event that happens in fewer than one in 50,000 routine cases of people being given an anaesthetic. The anaesthetist and the surgeon immediately tried to insert a tube into her airway. Additional medical staff quickly arrived to assist, including two recovery nurses, an ear, nose and throat surgeon and another consultant anaesthetist. For 20 minutes, the team desperately attempted to clear her airway.

Sadly, the emergency procedure failed. Elaine was transferred unconscious to the adjacent intensive care unit and died 13 days later.

Elaine’s husband Martin Bromiley was a commercial airline pilot. He knew how his industry would have responded to a similarly catastrophic event. One of the medical team told Martin that ‘maybe when this is investigated something can be learned. But we won’t investigate, not unless you sue or complain.’

‘For me as an airline pilot, that is where everything changed, because to me it is perfectly normal to investigate when something does not happen so you can learn from it, and here we had a situation where somebody was healthy, was going to be made more healthy, and was actually dead. I could not understand why you would not want to learn from it.’

It took some doing, but Martin managed to initiate an independent review of the case.

‘Arguably, it technically was a dream team to deal with this sort of emergency, but what we know happened, if you will excuse the phraseology, was that the situational awareness, the shared mental model of the three consultants, was different. They lost awareness of time; they lost awareness, perhaps more importantly, of the seriousness of the situation; they became fixated – which is not unusual under stress – on intubation to the exclusion of any other options, such as some form of surgical access.

From my background in aviation, I could see very quickly that these were in fact failings in what you refer to as “non-technical skills”: situation awareness, leadership, teamwork, prioritisation, communication, and assertiveness. These same human factors of failings in non-technical skills are the direct cause of 75% of aviation accidents.’

An incision into Elaine’s throat – a tracheotomy – may have saved her life. That it didn’t happen, was not the failings of any individual, but rather the failings of a flawed system.

Today, the findings from the inquest form the basis of training in Australia and elsewhere of healthcare clinicians, particularly those involved in advanced airway management.

The death of Elaine Bromiley was a tragic failure, but it was a failure that people learned from, and one that has improved the way in which emergency operating theatre procedures are conducted.

 

Is there a doctor on this flight?

Scientell is working with the Australian Council of Learned Academies (ACOLA) to synthesise a wealth of information into a book on securing Australia’s future. As part of this, we have examined the contribution that learning from error and failure can make to innovation and progress. This example demonstrates the way in which the medical profession is learning from the aviation industry’s approach to safety.

Safety is paramount for the aviation industry. Aircraft accidents are infrequent, but when they occur they involve massive losses of life. The exhaustive investigations that follow crashes have produced extensive literature into their causes, and new policies and regulations to improve safety. Research by the National Aeronautics and Space Administration (NASA) into aviation accidents has found that 70 per cent involve human error.

Writing in the British Medical Journal, Robert L Helmreich, professor of psychology at the University of Texas, states, ‘Error results from physiological and psychological limitations of humans. Causes of error include fatigue, workload, and fear as well as cognitive overload, poor interpersonal communications, imperfect information processing, and flawed decision making.’

‘In both aviation and medicine, teamwork is required, and team error can be defined as action or inaction leading to deviation from team or organisational intentions. Aviation increasingly uses error management strategies to improve safety. Error management is based on understanding the nature and extent of error, changing the conditions that induce error, determining behaviours that prevent or mitigate error, and training personnel in their use.’

Diagnosis should include data from confidential incident reporting systems and surveys, systematic observations of team performance, and details of adverse events and near misses.

It is now commonplace for medical doctors to learn from the approach to error and failure that has been refined and systematically adopted in aviation.

The error management approach that Helmreich advocates includes:

  • Dealing with latent factors that have been detected, changing the organisational and professional cultures, providing clear performance standards, and adopting a non-punitive approach to error (but not to violations of safety procedures);
  • Providing formal training in teamwork, the nature of error, and in limitations of human performance;
  • Providing feedback and reinforcement on both interpersonal and technical performance; and
  • Making error management an ongoing organisational commitment through recurrent training and data collection.

As physician Dr Lucian Leape, a physician and professor at Harvard School of Public Health, states:

‘The most fundamental change that will be needed if hospitals are to make meaningful progress in error reduction is a cultural one. Physicians and nurses need to accept the notion that error is an inevitable condition, even among the conscientious professionals with high standards. Errors must be accepted as evidence of system flaws not character flaws.’ [1]

 

[1] Lucian L Leape, Error in medicine. JAMA, 272:23, 1851-1857, (1994)

Robot servants: lending a metal hand

Robots are ideally placed to help with future housework, since they can perform repetitive tasks
without becoming bored. Since the 1927 film Metropolis, robots have lent a helping hand to humans in many science fiction movies, such as Star Wars, Wall-E and Elysium. The television cartoon series The Jetsons featured Rosie the robot maid.

Could robots soon take over the cleaning? Or, will they take over the world?

Real robots

Metal humans have featured in stories as old as Greek mythology. In 1818, Mary Shelley published her story of Frankenstein, the scientist who created an artificial human. A couple of years later, a science fiction play by Karel Capek called R.U.R. (Rossum’s Universal Robots) first used the word ‘robot’. The term was based on the Czech word ‘robota’, which means forced labour – so developing them in the real world as servants seems appropriate.

For more than 30 years, robots have performed repetitive tasks in car assembly lines. A typical
car factory today uses hundreds of robots. The military has used robots that can independently fly, refuel and select targets to attack.

Honda’s ASIMO (Advanced Step in Innovative MObility) robot, first unveiled in the year 2000, looks like a short astronaut. It can climb stairs, run, kick a soccer ball, dance, carry a tray of food, and knows to return to a power point if its batteries are running low.

However, the robots found in the home today are only vacuum cleaners or toys. A robot vacuum cleaner shaped like a large discus became available in the 2000s, and more than 10 million have been sold.

Robots rule

If robots can communicate with each other, teach themselves new things and learn without human help, could they team up and harm the human race? Not according to the famous science fiction writer Isaac Asimov, who came up with the three laws of robotics. These are: (1) a robot may not injure a human being or, through inaction, allow a human being to come to harm; (2) a robot must obey the orders given to it by human beings, except where such orders would conflict with the first law; and (3) a robot must protect its own existence as long as such protection does not conflict with the first or second law.

A scary idea is the possibility of computers with artificial intelligence becoming smarter than humans. This point in the future is called the ‘singularity’. After this point, it is impossible to predict or understand what such ‘intelligent’ beings would do. Perhaps they would compete with us for resources, or decide we were too harmful for the environment and exterminate us.

But in the meantime, those robotic vacuum cleaners don’t look too dangerous.

robots

For more on trusting a robot to clean your room, and 41 other inventions of the future, check out our book, Imagining the Future: Invisibility, Immortality and 40 Other Incredible Ideas, by Simon Torok and Paul Holper (CSIRO Publishing), http://www.publish.csiro.au/pid/7344.htm.

Faster food: 3D print your dinner

You arrive home from school, hungry for a snack. You feel like something different; not the usual food your fridge and pantry automatically order based on what you normally eat. So you search for a treat on the internet, find one that looks good, and press print. Your 3D printer creates a ready-to-eat copy. Meanwhile, your parents are in the kitchen printing dinner. Welcome to the high-speed, low-waste, good-health world of future food.

3Dfood

Entree
3D printers were invented in the 1980s. Rather than print an image using a layer of ink, they can print an object using layers of plastic or metal. Through the 1990s and 2000s, 3D printing helped in the design of new products and was used to make one-off prototypes of objects. Today, 3D printers are cheaper and more widely available. They are already used in mass production of items in factories and to print objects at home.

It is early days for 3D food printing. You can buy a 3D chocolate printer, which uses melted chocolate to print chocolate pictures and objects. Similarly, a sugar-based 3D printer can print sweets in creative shapes. A 3D pasta printer can print ravioli if you top up its ‘printer cartridge’ with dough and fi lling. Other 3D printers can mix together ingredients, or use pureed vegetables, to print food such as quiche, hamburger patties or corn chips. But 3D food printers are slow, depositing one thin layer at a time. And they can’t create food out of nothing: the food shapes are made from ingredients that were already edible before being transformed by the printer.

For more on what’s cooking in the world of 3D food printing, and 41 other inventions of the future, check out our book, Imagining the Future: Invisibility, Immortality and 40 Other Incredible Ideas, by Simon Torok and Paul Holper (CSIRO Publishing), http://www.publish.csiro.au/pid/7344.htm.

Sky highway

Flying cars are considered to signal the arrival of the future – or rather, the lack of its arrival. They have been promised by inventors for decades, and always seem to be just around the corner, but have never become commercially available.

Mass-produced flying cars are still not likely to be around the next bend. They face many possible problems, but NASA recently completed a study about making more use of the roughly 3000 small airports in the United States.

In the 1960s, flying cars were popular in fiction. The Jetsons, a cartoon family living in the year 2062, travelled by flying car. In more recent movies, Harry Potter travelled to Hogwarts aboard the Weasleys’ flying car, while Lucy Wilde’s car had extendable wings that enabled a
quick getaway in Despicable Me 2.

Keys to the real world

Flying cars are almost as old as flying aeroplanes, but none have really made it past the test stage to become widely available. In 1917, less than 15 years after the Wright brothers flew the fi st aeroplane at Kittyhawk in the United States, Glenn Curtiss invented a car with three wings and a propeller.

Robert Fulton tried something different in 1946. Instead of modifying a car to make a plane, he modified a plane into a car. His ‘Airphibian’ could be converted into a car in five minutes by removing the wings, tail and propeller. The following year, plans to build 160 000 cars with a huge wing, propeller and tail were abandoned after a crash when it ran out of fuel. Although the pilot had checked the car’s fuel gauge, the separate propeller engine’s tank was empty.

Henry Ford predicted in 1940 that ‘a combination airplane and motorcar is coming.’ He worked with engineers in the Ford company’s aircraft division to develop the first ‘aerocar’. The result was the Ford Flivver, a single-seat plane that could be driven along a road. However, the prototype was described by famous pilot Charles Lindbergh as one of the worst planes he’d ever flown. Furthermore, the Flivver’s test pilot was killed in a crash off the Florida coast, which stopped the small plane’s development. Henry Ford declared in the 1950s that, ‘the day where there will be an aerocar in every garage is still some time off.’

For more on this and 41 other inventions of the future, check out our book, Imagining the Future: Invisibility, Immortality and 40 Other Incredible Ideas, by Simon Torok and Paul Holper (CSIRO Publishing), http://www.publish.csiro.au/pid/7344.htm.

Flying cars

Eternity: could we ever become immortal?

People now live longer than ever before. A girl born in Australia today can expect to live for about 84 years, but a girl born in the late 1800s was expected to live for just 54 years.

We owe this improvement to better food, advances in medicine and having more money. Fewer babies and young children die, and our work and lives are far safer than they used to be.

What can be done to extend your life? Let’s start with the things you can control yourself.

First: watch your diet and weight. The Mediterranean area of Europe is home to lots of people who are more than 100 years old. Most people there eat healthy diets that are high in fruits, vegetables, nuts and healthy fats such as olive oil. Also, don’t smoke or drink too much alcohol when you are older.

Next: study. Educated people live longer. They are more likely to have better jobs and make healthier lifestyle choices. Be friendly. Strong social networks help support us; helping other people may help us better look after ourselves.

Exercise is good. Light physical activity every day leads to less disability in old age and a longer, healthier life. Stand instead of sitting. Sitting for long periods when studying, working and watching television is unhealthy, so try to spend some time doing these things on your feet.

For more on this and 41 other inventions of the future, check out our book, Imagining the Future: Invisibility, Immortality and 40 Other Incredible Ideas, by Simon Torok and Paul Holper (CSIRO Publishing), http://www.publish.csiro.au/pid/7344.htm

Climate of change

Ice and heat are enemies. As the world warms, the ice on the land melts. Most glaciers are in retreat, with their water gushing into the sea. This makes the sea level rise. Add the expansion of the oceans, which get bigger as their water warms, and we have a significant threat to coastal regions.

More than 150 million people live less than one metre above high tide level, and billions of dollars of homes, businesses and roads are located on the coast. In Australia, about six million people live within two kilometres of the beach. So what can we do when our cities and towns start to slowly slip under water?

Coping with climate change

Florida architect, Jacque Fresco, specialises in designing cities of the future. He has a vision of floating cities made up of interlocking, cog-shaped buildings.

A company called Freedom Ship floated the idea of an ocean platform more than a kilometre long that would slowly circle the world and could house 60 000 people. The barge would have high-rise apartment buildings, an onboard hospital, schools and a huge shopping mall. But the estimated $11 billion cost may sink this idea before it starts.

What about the millions of people on land who rely on glaciers for their water supply? Farmers in the northern Indian town of Skara grow crops such as barley. The farmers rely on meltwater from the Himalayan glaciers to water their crops. Because the Tibetan Plateau is warming quickly, the glaciers are disappearing, resulting in water shortages in India.

Years ago, an Indian engineer named Chewang Norphel noticed that slow-moving water freezes more readily than swift streams. He used his observation to make artificial glaciers, working with a team to set up canals and divert water from local rivers during winter. The canals slow the water and allow it to freeze. In spring, after seeds have been sown, the artificial glaciers melt and water the fields.

For more on this and 41 other inventions of the future, check out our book, Imagining the Future: Invisibility, Immortality and 40 Other Incredible Ideas, by Simon Torok and Paul Holper (CSIRO Publishing), http://www.publish.csiro.au/pid/7344.htm

Can we become invisible?

We all love the idea of being able to creep around, watching people without them knowing, eavesdropping on conversations. Think of all the fun you could have if, at the snap of a finger, you could become invisible.

Lots of books and movies have featured people who deliberately or accidentally became invisible, such as The Invisible Man and Harry Potter. In some stories, experiments with chemicals and nuclear explosions have made fictional characters become see-through.

Real-life invisibility

‘Stealth’ aircraft have radar-absorbing panels and are painted with a special coating. This deflects radar signals up or down, rather than back to the radar-detecting instrument, making it harder for the radar to detect objects.

A team from the University of Singapore has developed an invisibility gun. It makes things invisible by bathing them in a beam of darkness. Using a laser and a special lens, the researchers have used the darkness beam to hide a tiny three-dimensional model of the letter ‘N’. The method works only with small objects, so the challenge for the researchers will be scaling it up to the size of a person – if they really want it to catch on.

An English company has used tiny carbon tubes called nanotubes, each 10 000 times thinner than a human hair, to make a material they claim is blacker than black. The material captures 99.96 per cent of the light that hits it. When coated onto aluminium foil, it makes the foil almost impossible to see. ‘It’s like black, like a hole, like there’s nothing there,’ says a company spokesperson.

A nanotube material called Vantablack will be used in astronomical cameras and telescopes to reduce the reflections from stray light. This will let astronomers spot faint stars. If you could make a shirt from Vantablack, it would appear as if your head was floating in mid air, with your hands suspended nearby. Could this be just like the Harry Potter cloak of invisibility?

For more on this and 41 other inventions of the future, check out our book, Imagining the Future: Invisibility, Immortality and 40 Other Incredible Ideas, by Simon Torok and Paul Holper (CSIRO Publishing), http://www.publish.csiro.au/pid/7344.htm

Imagining the future: a guide to the incredible inventions just over the horizon

Imagining the Future book cover    Paul and Simon ABC tardis interviews June 2016

 

 

 

 

 

 

 

 

 

We are living in a rapidly changing world – when most of today’s primary school students grow up, they’ll have jobs that don’t exist right now, and they’ll be using technologies that haven’t been invented, to solve things we don’t know are problems yet!

Our new children’s book from CSIRO Publishing, Imagining the Future: Invisibility, Immortality and 40 Other Incredible Ideas, shows young Australians the world they may very well find themselves in, all based on current scientific advances. Printed food, talking with animals, designer babies, weather control, and immortality: some concepts are more likely than others, while some are already happening, but all have science behind them.

We need to get more young people hooked on science and mathematics and this book will teach the next generation how to dream big, believe in their ability to make dreams a reality, and turn science fiction into science fact.

If you can dream it, you can invent it. And inventors just keep on inventing. Get prepared for a fantastic future.

More information: http://www.publish.csiro.au/pid/7344.htm

19. Flying

Help! Lending a hand to vulnerable species

Global hotspots, such as the waters southeast of Australia, have warmed dramatically and dozens of marine animals have moved south. Many others need our help.

Dr Alistair Hobday, from CSIRO, says these sea temperature changes are clear – not only in the physical records, but also in the biology. ‘As the oceans have warmed, nutrient levels have changed, which is influencing productivity southeast of Australia,’ he says. ‘More than 100 species of fish and two dozen invertebrate species have moved south.’

With temperature rises having a dramatic impact, Alistair is investigating adaptation options for ecosystems as a whole, as well as individual species. In partnership with the Tasmanian Department of Primary Industries, Parks, Water and Environment, Alistair has investigated adaptation options for the shy albatross, a protected species that is in decline.

You can find out more at https://connect.coastadapt.com.au/discussion/72/help-lending-a-hand-to-vulnerable-species#Item_1

Scientell is working with the National Climate Change Adaptation Research Facility (NCCARF) on their online discussion about coastal adaptation, CoastExchange. You can sign up at https://connect.coastadapt.com.au/.