Emotions run very high when the topic of safety in eventing is raised, and as a passionate eventer for more than 25 years, I too am vulnerable to letting emotions dictate the tone of my message. However, as a physician-clinical researcher, I have been trained to think critically, analytically, and quickly in life and death situations, and I would like to apply this skill to the eventing safety crisis and to share what I see as the necessary strategy to surmount it.
I am not a current upper-level rider (I was very successful at Preliminary as a young rider years ago), so I do not claim to be approaching this topic from the perspective of a top-class eventer. Instead, I’m approaching this topic from the perspective of a physician clinical researcher with a background in eventing. My deep understanding of the sport is what makes me believe that the same principles I use every day in my career can be applied to make this sport safer for all.
I am a board-certified Pediatric Hematologist/Oncologist with an additional Master of Science in Clinical Research from Emory University. I am full time faculty at Children’s Healthcare of Atlanta/Aflac Cancer Center/Emory University, and about 80 percent of my time is spent on research (the other 20 percent is patient care). My research area of interest is patient safety, quality improvement and care delivery. Specifically, my work focuses on preventing infections in pediatric cancer patients.
Children with cancer are at high risk for infection: We give them high doses of chemotherapy to kill their cancer, but the side effects are that we wipe out their immune system and often damage their skin, mouth and GI tract, which are our body’s first line of defense against bacterial infection. As anyone with kids knows, it is difficult to keep them clean. Kids with cancer are no exception.
It might seem that preventing infection in these patients is a totally lost cause, especially because we do not try to keep these kids in a bubble during their treatment. However, we do not accept defeat when it comes to infection — accepting it would mean that kids would get very sick and sometimes die from the treatment they receive that is meant to cure their disease. So what do we do?
There are several strategies we use to address this problem from all angles. After each one, I will describe how the same process can be translated for use to address the safety problem in eventing.
Like many institutions, mine participates in national, multi-center, randomized control clinical trials to look at interventions that may reduce the risk of infection in pediatric cancer patients.
These trials have stringent protocols, specific enrollment numbers, and take years to complete, so if we waited to make any changes to our practice until the results were in, we’d be waiting too long and lives would be lost in the interim. Nonetheless, these studies are critically important to understanding how to prevent infections among this general population of patients.
Eventing Parallel: The Collapsible Fence Technology Research and the Equine Cardiovascular and Pulmonary Research studies from the USEA are two excellent, national, large-scale initiatives. These studies will provide us with invaluable insight that will surely lead to improvements in cross country safety, so we should be supporting them and any other large studies proposed down the line.
However, just as the national trials in medicine take time to complete and analyze, so too will these studies, and we cannot depend on these results to fix the entirety of the safety problem in eventing, especially when we have reached such a critical juncture.
Quality Improvement Initiatives
Simultaneously to participating in national clinical trials, we complete quality improvement initiatives. Quality improvement initiatives are not clinical trials, but rather are small, low-risk interventions targeted at our specific patient population with measurable outcomes that allow us to determine whether a change resulted in an improvement.
The principles that govern quality improvement and clinical research are different, and I won’t belabor them here, but the concept central to quality improvement is that it allows for the quick implementation of an intervention thought likely to have a positive, measurable impact on the outcome of interest in order to rapidly address a critical safety problem.
Quality improvement strategies are utilized by many different industries and have been mastered by high reliability organizations, which by definition are organizations that function in an environment where accidents are expected due to risk factors and complexity, yet they succeed in avoiding catastrophes. The FAA’s Air Traffic Control system is one example.
High reliability organizations are obsessed with failure and the reasons for it. Whatever the failure is, big or small, it is analyzed rigorously in order to ensure that the same failure never happens again. Healthcare continues to study and learn from the experience and success of high reliability organizations to improve safety, and never accepts failure as an option.
You continue to look for a solution until you get your failure rate to ZERO (which almost certainly will never happen, but it doesn’t stop us from trying).
Eventing Parallel: Quality improvement strategies can, and should, be applied to the safety problem in eventing, as it will be the quickest way to start seeing some changes for the better. There are plenty of easy, low-cost changes that can be tried over a period of just months; data can be collected from each event at which they were tried; and data can be analyzed using quality improvement principles.
If the changes result in an improvement, they can be sustained and new ones can be tried in addition, and if not, they can be replaced with other changes.
The types of changes I’m referring to here are simple and inexpensive ones, like improving ground lines or eliminating vertical faces to jumps or making qualifications for certain levels more stringent for horse and rider or any of the other suggestions wise horsemen have publicly suggested.
All of this is with the goal of getting the occurrence of rotational falls to ZERO! To be frank, it does not really matter whether we are better now than we were before or whether death from other causes or in other sports occurs or does not occur. All that really matters is that these incidents are happening in eventing at an unacceptable rate. Eventing needs to be just as pressingly obsessed with failure as high reliability organizations and healthcare, otherwise we give ourselves permission to put lives at unnecessary risk.
In order to effectively implement quality improvement strategies to make some rapid improvements, eventing organizations should not only consider including people with eventing experience to help decide what the first changes should be, but should also include people with expertise in quality improvement to help plan these initiatives.
Just as healthcare learns from and models itself after high reliability organizations, eventing needs to model itself after organizations that have implemented these strategies successfully and involve those with the experience to make it successful.
On the patient level, every single time there is an infection in one of our patients, we have a multidisciplinary meeting with nurses, physicians, epidemiologists, microbiologists, and others to do a “root-cause-analysis” to determine whether anything could have been done to prevent that particular infection. Sometimes the answer is yes, sometimes the answer is no.
The severity of the patient’s health outcome (whether the infection resulted in death or near death) has no bearing on the detail with which we analyze each event. Whether or not a specific infection is deemed preventable, we learn something from discussing each case, and where possible, plan immediate changes to our practice going forward to avoid similar situations.
Eventing Parallel: Rotational falls should be treated like infections: not a single one should ever be automatically written off as something that was not preventable, or a “freak accident,” and therefore doesn’t merit detailed discussion.
Every single time a rotational fall occurs, regardless of the health outcome for horse and rider, a root-cause-analysis discussion should happen, including the jump judges, the rider, the course designer, the officials, the rider’s trainer, perhaps a mechanical engineer, perhaps a physician, and at least one or two “experts” (upper-level riders) who can help facilitate the discussion and analysis of the event that occurred.
They may not be able to gather in the same room like we do in the hospital, but a conference call would accomplish the same goal. Just like in our discussion of infections, there may not be an identifiable or preventable cause for every single rotational fall that occurs, but each one needs to be examined critically and with rigor.
A Word on Data Collection and Analysis
Each of the strategies discussed above relies on the accurate, complete collection of data for review and analysis. The way in which data is analyzed for a clinical trial versus a quality improvement initiative is different, and in the hospital, we utilize professionals who have specialized training and degrees to help plan data management and analysis.
The quality of the information you gain from any study is only as good as the data you collect. The finer points of data management and statistics in order to draw valid conclusions are not something just anyone understands (however, anyone can put a chart together without ensuring that the analysis is a valid answer to the question at hand), which is why people get advanced degrees and are hired to do these analyses.
Should eventing organizations decide to employ some of the strategies I’ve discussed, it would be critically important to involve people with this skill set, and I know there are many eventer-epidemiologist-statisticians out there.
If we employ these various research, quality improvement, and case-based discussion strategies to the problem of preventing rotational falls, and therefore serious injury and death of horse and rider, I am certain we will see changes for the better. These are tried and true methods used by organizations big and small, facing equal if not greater risk.
The tragedies that have occurred this year so far are simply heartbreaking, and to me, unacceptable. I deal with death and grieving families every single day in my job. In my line of work death is, unfortunately, expected in many cases but it doesn’t mean we don’t do our very best to try to prevent it from happening to the best of our ability, using all of the resources at our disposal.
I truly believe that the very best way we can honor the memory of the lives lost this year is to dedicate ourselves collectively as a global eventing community to making the sport they all loved safer.