Prevention and Odds, Protecting Children with Lean Thinking


    Thursday: Newer pools minimize risk of drain accidents, officials say

    You might have seen this heartbreaking story on the news, the 6 year-old girl who suffered gruesome injuries from a swimming pool drain.

    These tragedies are somewhat common, when viewed from the perspective that one such tragedy is too many and that these events should be 100% preventable. They're somewhat “rare” if you look at the world from the standpoint of “what are the odds….?”

    At least three other children have suffered similar injuries since 1990. And 33 others have died, most when they were trapped underwater by the drains in hot tubs or pools, according to federal reports.

    From the reports, there are a few preventative measures that could help, let's look at them from a Lean perspective:

    Since 1990, 170 people, mostly children, have been caught in drains and 27 of them have died. Legislation is pending that would require pools and hot tubs to have multiple drains to ease the suction.

      Here's a good example of error proofing through re-design. One of the root causes of this type of injury is that the pool suction is so strong to begin with. But, it's not realistic to think we're going to retrofit all of the existing pools in the country.

      Some pools have a safety vacuum cutoff which shuts down if someone is trapped. New drain covers which cost less than $50 can also help.

      The cutoff is a nice error-proofing feature, but is that something that can retrofitted?

      The idea of a $50 drain cover, one that's less likely to trap swimmers is a great idea — inexpensive and easy to retrofit, I'd assume.

      But what about “process” based solutions? There are allegations that the pool operator knew the cover was off or loose. You'd think it would be part of the operator's “standard work” to inspect these covers frequently and to shut the pool down completely if there was any delay needed in repairing or replacing the cover.

      Now, I hope nobody is a smart-aleck and suggests that ultimate “error proofing” would be to ban swimming pools.

      I heard one commentator on TV news downplaying the safety risks, she put the problem in terms something like “the odds are very slim…. 1 in 180 million….”. That might be statistically true, but that doesn't mean that the chances of an injury like this are the result of pure chance.

      I can cut my chances of this sort of injury to zero by not swimming. But, an approach that combines simple, inexpensive error-proofing with standard work and process improvements… now that's a Lean sounding approach that can save lives!!

      If you're a parent who takes their kids to a city or community pool, you might want to do some proactive FMEA work rather than relying on “odds.” We shouldn't gamble with safety.

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      Mark Graban
      Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


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