From: ILPI Support <info**At_Symbol_Here**ILPI.COM>
Subject: [DCHAS-L] NYT articles on surgical checklists that helps explain why methanol incidents continue.
Date: Fri, 11 May 2018 13:30:02 -0400
Reply-To: ACS Division of Chemical Health and Safety <DCHAS-L**At_Symbol_Here**PRINCETON.EDU>
Message-ID: 13973030-EBC3-42CF-BE48-0B06D2CA9E12**At_Symbol_Here**

This article from the New York Times explains how surgical checklists can make a significant difference in mortality outcomes:

Later in the article they explain an intensive eight month peer-coaching program to implement a childbirth checklist and see how it performed in a study of 160,000 pregnant women in India.  The impact?  None. Per the article:

"What happened? How could an idea that worked so effectively in so many situations fail to work in this one? The most likely answer is the simplest: Human behavior changed, but it didn't change enough. Coached attendants washed their hands 35 percent of the time, while the uncoached group, the control group, washed only 0.6 percent of the time. Coached birth attendants measured a newborn's temperature 43 percent of time, compared with participants in the control group, who measured it 0.1 percent of the time. Yet these differences in behavior weren't ample enough to have an impact on maternal or fetal morbidity and mortality."

And yet other implementations elsewhere worked just fine.  The article continues:

"In the childbirth trial in India, 35 percent of the attendants started off washing their hands during the first months of the study, while coaching and supervision were still active. By 12 months, when the coaching had ceased, that proportion had dropped to 12 percent.

We might describe this situation as a "behavioral relapse," akin to the physiological relapse of cancer or of an immunological illness. Unlike cancer, though, behavioral relapse has no measure: no marker, no biopsy, no powerful predictive test; it remains undetectable by most methods. As much as we need experimental tools to survey human physiology, doctors need experimental tools to understand, survey and change medicine's least familiar frontier: human behavior."

I see a strong parallel to the problem of demonstration solvent fires that we have all been working so hard to end. The issue is that human behavior and focus is finite and without reinforcement good habits will lapse unless reinforced.  And most K12 science teachers operate in a near-vacuum with only a limited number of colleagues to reinforce safety behaviors such as risk assessment and hazard determination that, when lapsed, most often do not carry immediate consequences and lead to a deepening pool of complacency.

The only "real" solution to this specific issue is going to be an inculcation of safety culture at the teacher training and continuing education level.  We've all been fighting that battle as well, but only by making safety an integral part of everything we do as chemists and teachers will we finally win this battle.  It is encouraging that the ACS has finally taken up safety as a core value, but there is a long way to carry this mantle before victory.  Keep up the fight!

Incidentally, I wrote to PBS's Frontline (documentary/investigative reporting show) suggesting they consider covering the K-12 solvent fire issue.  I provided them with info about this week's incident in TN along with background info about the Rainbow experiment etc.  Here's hoping they bite or at least nibble.

Rob Toreki

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