Tami Strong - R4L Founder
I was asked “why did you create the Reliability 4 life group?” in an interview recently. My answer started with a description of what we do, what differentiates us from others dedicated to reducing harm, and my credentials to establish my qualifications as an “expert”. Then as I paused and took a deep breath, tears began to well, “to be honest, behind this smile is a lot of pain”. Losses have shaped who I am and what I do. Patient safety is not my job – safety is my passion.
As a young girl, my grandmother McKenzie was my best playmate. She loved me dearly. Unfortunately, my grandmother’s medications were mismanaged by her medical team. She had so many meds she used a green suitcase just to carry her meds. Grandma McKenzie died at age 68 of heart-failure related to that mismanagement. The little green suitcase in the photo with me represents the meds which killed her.
My stethoscope in the same photo captures the pain of two clinical events forever changing my life. I always wanted to care for others, perhaps by becoming a doctor or a nurse. My original career out of Michigan State led me on a different path, but I found my way back. I studied to be a nurse. My first healthcare job was in a surgical intensive care unit. With a technical background and maturity behind me, ICU nursing seemed to be ideal.
Our nurse preceptor was a brilliant nurse. Her experience and high expectations were intimidating. Even with all of those life experiences working in a tough automotive manufacturing environment, my fear of speaking-up to her when I was unsure was greater than my concern for my own safety. I continued even though anxious and unsure. Seconds later, panic and tears engulfed me as a contaminated, wide-bored needle plunged into my finger. Our patient was very sick with an infection threatening his life, and that infection would now threaten mine.
Years later, I was caring for a lovely woman in chronic-renal failure who was recovering from surgery on our unit. I met her family - we all bonded. One evening she was not as alert, and her vital signs trended downward. I got her help – I got us help. But then her physicians argued about who should help the patient so by the time our charge nurse got even one physician to the bedside, I was again in a state of fear and panic for my patient’s life.
I didn’t know the doctor, and she didn’t know me. I had made a thinking error in recommending a med. The doctor followed me with her own thinking error in ordering the med. My patient coded and died a few minutes after administration. I believed I killed her. I drove home that morning and composed in my head my letter of resignation, finished after only three years as a nurse. With resilience which I still do not understand, I chose to stay.
In 2013, I thought my life would end after my father died suddenly. Dad is also shown in the photo. He had a rare type of cancer, very lethal unless contained. He survived an intense surgical procedure, and when he woke, he was rid of the cancer. Our miracle was taken away within 24 hours of discharge. He died from an unrecognized blood infection - sepsis. Dad died a horrible death in front of my mother. His death certificate was wrong, stating he died from cancer. As if his cancer could recur and kill him in 24 hours. He died from system-caused human error.
After all this loss, the best thing that could ever happen to me was learning how error happens, the safety science, and how to organize for a culture of high reliability. Through many years of practice in re-engineering cultures for safety and high reliability and talking with thousands of leaders and caregivers, I found myself helping to save lives. And I too am healing. The poison of anger, blame, shame and guilt have transformed to the medicine of compassion and forgiveness.
Through my previous work and my interactions with thousands of leaders and caregivers, I have seen the power of high reliability cultures to save lives and promote healing. I have also learned that harm can occur in any setting, and that we need to promote access to Life Skills beyond the workplace. By understanding and living reliably, we can reduce the harm and defects that impact us all. Ultimately, my personal experiences with loss have driven my passion for this work, and I know this work will make a meaningful difference in the lives of others.