After more than 30 years on the faculty at Thomas Jefferson University, which included 18 years at Sidney Kimmel Medical College, I think I know a thing or two about recognizing “a teachable moment.” Astute readers will recognize this phrase, because every clinical attending physician, especially those in internal medicine, wait patiently for such a moment. In general, a teachable moment means that we drop everything to huddle and recognize a take-home message. A teachable moment reinforces the reading we do in the evening with the clinical care we deliver during the day.1
A teachable moment can also be nonclinical—that is, an opportunity to review aspects of the biosocial model in medicine, improve our communication, and of course, explain how we might improve the level of quality and safety of care that we deliver. Sadly, I believe that the recent death of the well-known cinematographer Halyna Hutchins on the set of the movie Rust that was being filmed in rural New Mexico is just such a teachable moment.
A few caveats are in order. I am not an expert in modern culture. In fact, my grown children may be right in their view that I am somewhat of a cultural troglodyte. I certainly am not a movie critic, and clearly, and fortunately, I am not a celebrity watcher. However, I am an expert in healthcare quality and safety, and I can’t resist the opportunity to draw some analogies between the tragedy on the set of the movie Rust and our understanding of a teachable moment in quality and safety. Please allow me to elaborate.
As many readers probably know by now, in early October 2021, the actor Alec Baldwin was playing the role of Harland Rust, a grizzled outlaw, who was cornered by a sheriff and a US marshal in a small wooden church. Rust the character decided to shoot it out with these lawmen as a way to save his grandson from being executed for an accidental killing—a true Hollywood storyline!
As you likely know, tragedy ensued on the set, which made worldwide headlines with the death of Ms Hutchins and the severe wounding of the movie’s director, Joel Souza. Lawsuits have followed, and there is yet no resolution of the turmoil that was widely reported.
Now, let’s evaluate what happened on that set, as best as I am able to ascertain from newspaper reports, and frame the conversation in the vocabulary of quality and safety in healthcare. There clearly was a lack of a “just culture” (ie, “open communication of errors in a nonpunitive environment”) and the presence of a “blame culture” on the set of this film.2 According to a newspaper report, just the night before the shooting, 6 members of the film crew had resigned.3 This tension was in the background amid a broader labor dispute with support from their union, the International Alliance of Theatrical Stage Employees.3
Given the pressures of filming in a pandemic environment and missing multiple deadlines, reports state that crew members were extremely disgruntled about their living conditions, safety concerns, and poor communication on the set.3,4
The lack of a just culture is probably a bellwether, because it relates to setting the stage for quality and safety failures. There clearly was a lack of a safety mindset on this movie’s set, based on these reports. Only a couple of days before the fatal shooting, at least 2 accidental gun discharges occurred on the same set.3,4 In fact, it was reported that persons involved in checking the weapons were also responsible for previous safety lapses while filming another movie starring Nicolas Cage.4
Furthermore, there was clearly inadequate training for frontline workers, as has been widely cited.3,4 There were concerns about the on-set armorer, Hannah Gutierrez-Reed, because she was only 24 years old and had been assigned the job of chief armorer.4 According to documented sources, Ms Gutierrez-Reed claimed that she was still learning on the job and “wasn’t sure if [she] was ready.”3,4 Can one imagine a healthcare worker citing a similar paltry excuse when an error, especially a fatal one, might have occurred?
In my judgment, there was also a severe lack of adherence to established protocols and ignorance of a checklist. Again, documented evidence notes that Ms Gutierrez-Reed and Dave Halls, the assistant director on the set, were supposed to double-check all weapons before handing them to the actors; apparently, this never occurred.3,4 We have learned so much from the past about the power of the checklist, and the importance of transparent and open communication.
It is evident that there were unclear lines of command on the movie set, which is a telltale sign of a decrease in quality and safety. In his role as assistant director, Mr Halls should have been the chief safety officer on the crew. In Hollywood, the assistant director is sometimes known as “the enforcer.”4 The job of juggling such pressures on any set falls to the assistant director on a low-budget film, which can be made harder by the tight financial resources and scheduling deadlines.4
Based on my assessment of the published reports of the shooting, I also believe that there was a low probability that persons could successfully go against the authority gradient—in this case, Mr Baldwin. Newspaper reports noted that there were days of grumbling and disappointment by the crew.3,4 In fact, the cinematographer who was killed was generally regarded as a peacemaker on the set, who had taken disgruntled crew members (who had just resigned) out for dinner the night before the fatal shooting.3
The lack of a just culture, and the inability to go against an authority gradient, go hand in hand and are a deadly combination. Experts in quality and safety can recognize from the description of this tragic event that the lack of a just culture, lack of a safety mindset, inadequate training for frontline workers, refusal to follow protocols, an unclear line of command, and the inability to go against the authority gradient all lined up, if you would, like holes in Swiss cheese.
In a recent editorial in the Wall Street Journal, Harvard scientist Nicholas Christakis connects the dots between the work of British psychologist James Reason5 in the early 1990s and our more recent understanding of how multiple errors that seem to be disconnected in time and space actually align perfectly to create the opportunity for a tragedy to occur.6
I’m not a connoisseur of modern culture, but I know a Swiss cheese model when I see one. This tragedy on the set of Rust is a classic Hollywood-style teachable moment. Let’s take this opportunity to review the components of the Swiss cheese model and to apply our learning everywhere, including at the office, in the hospital, the urgent care setting, and even in telemedicine.
- American Medical Association. Teachable moments. http://edhub.ama-assn.org/collections/44067/teachable-moment. Accessed December 18, 2021.
- Center for Patient Safety. Just/accountable culture. https://forward.centerforpatientsafety.org/just-accountable-culture. Accessed February 23, 2022.
- Romero S, Bowley G, Jacobs J. Reconstruction of a shooting reveals a troubled set. New York Times. October 31, 2021:A22. Accessed December 18, 2021.
- Flint J, Frosch D, Sayre K, Kesling B. Behind movie death, a set in turmoil. Wall Street Journal. October 30, 2021:A1. Accessed December 18, 2021.
- Reason J. Human Error. Cambridge, UK: Cambridge University Press; 1990.
- Christakis N. How the Swiss cheese model can help us beat Covid-19. Wall Street Journal. November 13, 2020. www.wsj.com/articles/how-the-swiss-cheese-model-can-help-us-beat-covid-19-11605283134. Accessed February 23, 2022.