From the Director: Reflections on the Texas Shooting

Do you remember when jet airplanes full of passengers used to crash more often?  When there was at least one major catastrophe resulting is significant loss of life each year?  Sometimes more than one per year?  And remember when disease and accidents took lives in great numbers?  Remember when an embolism or other medical error meant certain death?

In the past twenty years, there has been a quiet revolution in the world of airlines and medicine.  Simply put, the number of pilot and doctor errors have substantially dropped through the use of checklists.  Flying a plane or open heart surgery require multi-faceted interactions with complex machines and even small errors can result in catastrophe.  In fact, it is a series of small errors, studies show us, which are at the center of catastrophic plane crashes and catastrophic medical interventions.  The use of check lists by pilots and doctors have resulted remarkable safety in the skies and remarkable recoveries in hospitals.

As I reflect on the prevalence of domestic violence in the lives of the people who commit acts of mass-murder, I wonder what would happen if we looked at domestic violence in the same way that the airline industry approached making flying safer and the world of medicine approached achieving higher survival rates.  The most recent mass-murderer, Devon P. Kelly was able to purchase four firearms from licensed dealers despite having been convicted of a crime that should have put him on a no-buy list.  There was an egregious error committed by the Air Force and now the Department of Defense is investigating the possibility that there are many others who should be on the no-buy list but who are not.  The result of the Air Force error was that Mr. Kelly shot and killed 26 people, including children, at a church in Texas.  Mr. Kelly was convicted of domestic assault of his then-wife and stepson.  He was dishonorably discharged from the Air Force as a result of this conviction.  He served a one-year sentence.  At each of these moments, our systems had a glimpse into the risk factors present in Mr. Kelly’s life and behavior.  He was a plane crash waiting to happen.

In fact, effectively intervening in domestic violence is a complex business.  It requires a number of complex systems to interface with both the abusive partner and victims as well children and other family members.  The lives of all of these people are incredibly complex since they are impacted not only by domestic violence but also by all the normal life-molding conditions that exist in everyone’s lives.

What would happen if there was a check list, or a series of check lists that could be used by the people working with in systems?  Is it possible to decrease or even eliminate domestic violence fatalities using such a list?  What if a cross-system method for ensuring that all domestic violence situations were evaluated for risk at the appropriate points, that the policies and laws designed to increase victim safety were implemented in each case, that the people involved in domestic violence had a full menu of options to increase not just safety but also healing and learning about engaging in healthy relationships?  What if a check list used across disciplines resulted in community-wide collaboration and coordination?

Far too many people die because of domestic violence.  For each person who dies, whether they are the victim or abuser, there is a whole galaxy of family members, friends, co-workers and communities which are impacted.  Could the use of check lists safe the lives of even one person?  Wouldn’t it be worth it?