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Quality and safety are rarely simple
  1. David P Stevens
  1. Dr David P Stevens, Quality Literature Program, Dartmouth Institute for Health Policy and Clinical Practice, 30 Lafayette Street, Lebanon, NH 03766 USA; David.P.Stevens{at}Dartmouth.Edu

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I live on an island 70 miles from Boston. I occasionally travel to the US mainland by ferry, but more often via a small airline with nine-passenger planes that are usually flown by a solitary pilot. The pilot’s preflight checklist is a small plastic card, usually reviewed in a matter of seconds—arguably, a simple task. One checklist item is to assure that the flaps are retracted, unlike jetliners that take off with flaps lowered to increase the wing surface area for lift. On a recent flight, the pilot reviewed the checklist and proceeded down the Boston runway. At an altitude of perhaps 10 m, her right hand momentarily moved off the throttle and quickly activated the lever to fully retract the flaps. In spite of reviewing the checklist, she had initiated takeoff with the flaps down. Was this caused by momentary inattention? Boredom? Perhaps she had recently piloted larger planes. Checklists and professional autonomy are brought to mind with increasing frequency, and, as in this case, not always in reassuring settings.

A COMPLEX CONTEXT FOR SIMPLE TASKS

Given the attention …

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