In 2007, an advertisement¹ promoting an exhibit at the Denver Museum of Nature and Science on the sinking of the Titanic read as follows:

It wasn’t an iceberg that sank the Titanic. You need to go much deeper to find out what really sent her to the bottom. The iceberg was just the last link in a tragic chain of events. It all started with the ship’s design. The hull sections were built with zinc, a material notoriously brittle when exposed to freezing temperatures. These sections were then bolted together with cheap iron rivets which began popping as soon as the ship entered icy waters. On board, the crew was so sure of her unsinkability that they began to ignore basic safety rules. Lifeboat drills were cancelled and the radio room was frequently empty. When it was manned, it had such outdated technology that the wireless operators couldn’t keep up with the influx of messages, including several urgent iceberg warnings. At 11:40 p.m. on April 14, 1912, the Titanic hit an iceberg. As the ship began to flood, the wireless operators were frantically sending out emergency signals. Except, they were the wrong signals. Instead of sending SOS, they sent CQD, a signal that had been out of use for some time. By the time they realized their mistake, the Titanic was beginning her final death throes. Even the Titanic’s distress flares, seen by a nearby ship, were thought to be part of a fireworks display and ignored. Almost three hours after it was hit, the Titanic sank with the loss of 1,522 lives. But what really sank her? Was it greed? Complacency? Human error?

The Titanic tragedy is frequently employed as an object lesson for patient safety, but sometimes we, too, focus on the iceberg, i.e., the last thing that happened before a patient was harmed. Only when an adverse event undergoes a comprehensive root cause analysis (RCA) do we begin to see the less visible, systemic problems that enabled that constellation of errors to place that patient, and future patients, at risk. Individually, and through aggregate analysis, RCAs help to expose structural weaknesses, shortages, gaps in technology, and overconfidence that can put patients and providers in deep water. 

Additional Reading

• Effectiveness and Efficiency of Root Cause Analysis in Medicine
• Lesson of the Titanic: the Healthcare System, Like the Doomed Liner, Faces Peril
• Sinking the Unsinkable: Lessons for Leadership

Reference

1. Developed at Carmichael Lynch, Minneapolis, by executive creative director Andrew Clark, and copywriters Tim Gillingham and Ellie Anderson.