The Swiss Cheese Strategy
Things Learned From…
The Premonition: A Pandemic Story, by Michael Lewis
![The Premonition: A Pandemic Story by [Michael Lewis]](https://substackcdn.com/image/fetch/f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2Fe3203802-f8ed-497d-ab2a-ceec64bfa123_327x500.jpeg "The Premonition: A Pandemic Story by [Michael Lewis]")
Dr. Carter Mecher is a fascinating person in Lewis’s book. He has a unique ability to reduce systematic error and simplify important decisions. My favorite examples are below.
Studying systematic error in the VA health care system
[Mecher] set out to learn everything he could about the inner workings of the human mind, and where and why it was prone to err.
He found a book called Human Error, by a British psychologist aptly named James Reason.
“It was like reading the owner’s manual of the human mind. Not the usual owner’s manual, but an owner’s manual that pointed out all the peculiarities and idiosyncrasies of how we operate—especially under conditions of stress.”
The ICU was a stressful and complicated place; Carter had experienced what Reason described.
He was struck especially by Reason’s argument that the best way to guard against error is to design systems with layered and overlapping defenses.
There was an image of Reason’s that Carter loved, of slices of Swiss cheese being layered on top of one another, until there were no holes you could see through.
Studying almost mistakes
Aviation safety, for instance. Whenever two planes almost collided, the Federal Aviation Administration knew about it and investigated.
But when a nurse screwed up and gave a patient medications intended for another, no one made a note of it unless the patient died.
“That stuff resonated with me like crazy,” said Carter. “You can keep mistakes from happening if you can identify the almost mistakes.” […]
“We need an incident reporting system in medicine. We focus on the bad event. We ignore what didn’t happen. We crucify whoever was in the bad event and ignore the others. And that’s not how you fix the system.”
The Swiss Cheese Strategy During the Pandemic
The solution would be a layering of multiple strategies, sort of the way you laid slices of Swiss cheese on a sandwich, so that the holes did not align. […]
there were things you could do to buy time before a vaccine. He’d coined a phrase for their strategy: Targeted Layered Containment. TLC.
TLC’s basic idea was the same as that underpinning Carter’s approach to medical error.
No single intervention would stop a flu-like disease in its tracks, just as no single safety measure would prevent a doctor from replacing the right hip when it was the left hip that hurt.
The trick was to mix and match strategies in response to the nature of the disease and the behavior of the population.
Each strategy was like another slice of Swiss cheese; enough slices, properly aligned, would hide the holes.
Mecher’s Version of Regret Minimization
In January 2020, before anyone knew how severe the pandemic would be, they had to decide whether to give hundreds of millions of dollars to companies that believed they could make vaccines faster than ever before.
Carter already had a view about these kinds of decisions. He thought that they should be approached the way an ICU doctor treated a patient clinging to life.
Play forward whatever you are thinking about doing, or not doing, and ask yourself: Which decision, if you are wrong, will cause you the greatest regret?
Thanks for reading! Hope you have a great day.