Welcome to the first one of the new year, and it's great to see great turnout, and these are often linked also to the cross, to the church.
I'm not sure if that's going on today or not, but anyway, it's great pleasure to introduce Helen,
who many of you know, consultant anaesthetist of Oxford since 2001,
senior clinical research fellow in the Department of Clinical Neurosciences at the
University and director of the Oxford University's Stimulation Centre and Simulation Centre.
I beg your pardon. Just checking that you are all the way.
She is current executive member and immediate past president of the Association for a simulated practise in health care.
We'll put that down now. Thank you very much, David. Thank you.
It's really nice to be here and to start on such a light-hearted note.
I'm going to be talking about something I feel is quite serious, but I think Peter and I feel really passionately about this and when.
Back in 2013, when we formed the Patient Safety Academy,
it was really the first thing we started talking about as a as a potential project across the region.
And so we began with the idea that we would teach some incident analysis more generally and how one does it,
how one deconstructs incidents and thinks holistically about what's happened rather than the more,
dare I say, ill formed root cause analysis process that the NHS advocates.
So what I'm going to talk about this morning is that human factors approach to instant analysis.
I'm going to talk a bit about the background about why we should be doing this.
I hope it's pretty obvious. And then explain this external review project that we were involved in because I still have hope that it will restart.
And, you know, we'll get it going again across the region and perhaps nationally.
There's definitely interest from from many national bodies. So that's my hope.
And then finally, I can you see, I've put lock slips in little letters.
Yeah, because I didn't want to freak you all out.
It's actually something again that Alastair and I are working really hard on with Rachel and Helen in this big group.
But I think I would really like to emphasise why it is.
That checklist can support safe practise, and I'll go into that in a little bit of detail at the end.
I'm going to make sure I get you all out of here on time as well.
I absolutely promise because I know one of my friends in here has a hair appointment,
and that's particularly important as you're going to kill me for saying it. OK, so why?
I love this figure from Robyn Furness paper,
where he suggests that health care is rather more akin to bungee jumping than to a flight on British Airways.
And unfortunately, I think that's still the case.
If we look at the data. The very first red flag that was waved was back in 91 in the New England Journal from Lucien Leak's Group,
and they did an exhaustive retrospective review of over 30000 sets of case case notes from 200+ acute
care settings and discovered that one in 200 patients would die as a direct result of an adverse event.
And so at that time, a lot of hands were thrown up in horror. You know, how very dare you suggest that we're harming our patients?
That was not what they were suggesting at all.
They were suggesting they were there were system wide problems that were leading to errors in health care.
And then after that? There are an enormous number of kind of meta papers that were delivered from developed health care systems around the world,
including our own Sir Charles Vincent wrote this one.
And he actually looked into in addition to the number of deaths that would result from adverse events, he said.
Look, if if the if the patient doesn't die as a result of this adverse event,
if we just kind of harm them a little bit, how much longer are they going to stay in hospital?
And he calculated that it was on average, another eight days.
And so the cost to the NHS at that stage was over a billion pounds, and you can see that that's quite a long time ago now.
So unsafe care is expensive, but actually, where have we gone since all this evidence has been highlighted?
And unfortunately, it would appear that certainly if you believe what most Amachree is saying, that it's actually underestimated what's going on.
And I think that's probably because an awful lot more evidence has come out about how these things happen in complex, fairly chaotic systems of care.
So whilst there are pockets of excellent activity, I think I would I would agree with Charles when he says that,
you know, all in all, what we're not seeing is widespread, sustainable change to reduce error.
So I'm a big fan of Demings, and I absolutely agree with wholeheartedly agree with this statement.
It's always about the system in the process, a little bit about the people, but you've got to be looking at systems and processes.
Of course, we do design the systems and processes. And so, you know, it kind of behoves us to be thinking about what we do with them.
So I'm just going to unpack. I don't like, I'm afraid, using the words never event, so I won't.
This is the American nomenclature. They call them sentinel events.
And this is an investigation that I did fairly recently in dermatology, and I picked it because it is a surgical problem.
OK. But in a different culture. And that's what interested me so much about this particular event.
So this is a team that has a very busy, busy outpatient department and a patient came in for the removal of a skin lesion.
They do a lot of this, if the nation wasn't marked, there was no computer screen and theatre for them to confirm it.
And it was hard for the patient to confirm where the lesion was because it was on his back.
The WHO time up didn't involve the nurse. She was busy unpacking the kit and then they removed the wrong lesion.
I mean, what a bunch of idiots. Until actually you realise that it always looks more like this.
So many other influencing factors around organisational issues, culture, team working and communication tools and technology,
the environment and so forth, and there's often a little bit of bad luck as there was in this case.
And if we don't unpack them, then the result is that we usually think that what a bunch of idiots.
So I quite like using these very straightforward tools to think about how errors occur, and I don't we should read this.
I just want you to see that under the people column, there's only a little bit of information.
All of it sets in culture, equipment and task and system. OK.
Not to do with the people.
Now the paradigm shift, as has happened in high reliability organisations like civil aviation, nuclear power, the railways, those kind of groups.
Is it instead of saying who did this? They say, How did this happen?
And so instead of seeing the human being is the cause of failure and error, they say, look.
Because, you know, there may be an aspect of human error here,
but it's likely that that was caused by other wider systemic vulnerabilities that we haven't understood clearly.
And when you're describing what happens in an incident a bit like that, well,
they took the patient comes in, didn't market, didn't do the WHO properly took the wrong vision of.
That's quite a satisfying way of describing the error.
But what it doesn't do is explain why it made sense for the individual or the team involved at the time to do what they did.
It's meaningless. And I don't know how many of you have had an email from On High, which says, Now listen, everybody.
Mrs. Smith got 10 times a dose of insulin post-operatively the other day on Ward 38.
I want you all to be a bit more careful, please. Yours sincerely.
And not helpful. That's never, ever going to help, just makes people cross.
It is only.
Why always being aware of the potential vulnerabilities within a system that we're going to learn and adapt if we're always on the defensive?
We're never going to be able to say, Right, okay, everyone, let's work together on this.
Let's trust each other and fix it.
So this report that was back in back in 15, it was released in the select committee highlighted quite nicely the fundamental flaws.
Frankly, what it says is that instant analysis within health care is not fit for purpose.
For many reasons. And unfortunately, it is destructive to both staff and families.
And so in 2017, the Healthcare Safety Investigation Branch was born each step along the lines of the AAIB,
although of course, in health care we don't have black boxes which are sacrosanct.
We have a duty of candour, so we do have to explain what's gone wrong to the families and carers and so forth.
And that's important, but it does mean that that information is then out there to be judged by whoever wishes to judge it.
So what we thought was that it would be good to work across our region because we're a pretty compact, fairly geographically close group of hospitals,
acute care settings and see if we could think about developing an external review process where groups of investigators from
different trusts around Thames Valley would review each other's incidents or support each other in investigating incidents.
So we revised educational materials and we thought, Well, you know, how are we going to think about the data?
And we realised that it would be quite a lot of cool data, but a little bit of quantitative evidence.
Anyway, we what we found, perhaps not surprisingly,
that there was a clear lack of human factor skills across the board in the trusts in Thames Valley.
And there was absolutely a lack of standardisation of approach to instant analysis, right down to the fact that all the forms are different.
Wherever you go, there was a huge variability in level of support for people who were investigating and time that was given a
variability in the way decisions were made about what level of investigation was necessary for particular incidents.
And you know, in this organisation,
we have a meeting every Thursday morning at which we discuss what level of investigation and a consensus is achieved.
So there are quite a lot of conflicts of interest, of course, you know, there is no no,
no high reliability organisation investigates its own naval like we do.
I mean, it's completely bonkers. You know, you're asked to investigate an incident that has happened in your trust,
often within an area where, you know, you know, people, they'll be your friends.
And so it's it's impossible for the for no bias to exist.
Well, that's impossible anyway. But it's far less likely when you work in the organisation, you pay by them.
And of course, what was really interesting and perhaps most challenging was that persuading medical directors around the region that
we wouldn't be displaying their dirty laundry for everyone to see was a huge challenge really was very difficult,
quite surprisingly difficult. And we had to develop an emoji to to to reassure them.
So we set up this project, we trained some trainers, and what we wanted to do was support them in increasing the openness and transparency,
the sharing of learning around the region to develop a consistent way of investigating serious incidents in health care.
And obviously to enhance.
Hopefully, the knock on effect will be enhancing the quality of other internal investigations that were going on in the organisation.
So we engaged with medical nursing directors. We designed a template,
the new template for the investigations delivered the training and then we compared the results
of internal investigations against the results of external human factors led investigations.
So we had a couple of investigations for trust, which was what we were hoping for.
And all of the investigators were supported by human factors, expertise from us in the Patient Safety Academy.
Within the training, we wanted to explore two straightforward models of human factors analysis to support them in doing this.
And these were the two that we picked, but we also explained that there were others out there.
And frankly, you just choose the one that suits you best.
I think both of these are good for me was fine. They will have the little nuances, but that was what we were teaching.
Use these models as a framework for thinking about what's happened in this incident.
So the barriers I've already mentioned, the reluctance to take part in the indemnity issues, the logistic difficulties were also quite substantial.
Sharing information across, you know, regions. So if you if you've got investigators from Milton Keynes coming here to look at one of our incidents,
it was it was quite challenging getting the time and aligning everyone and data reports.
Anyone they wish to speak to these kind of things was difficult.
And then, of course, completing the timely report because you've got 60 days, for example,
from the point of a of a of a sentinel event occurring 60 working days to completion of the report.
So I'm going to give you a couple of examples just to show you how this worked. So this is a more surgical example of surgical examples, actually,
but this is a 64 year old male with lung cancer, complex problems, complex co-morbidities.
He'd had previous thoracic surgery and he came in breathless.
So he was admitted under the medicks. OK, that seems sensible.
They discovered an emergency infusion on his X-ray.
Quite a substantial effusion, and he had quite bad chest pain.
He'd been in and out of the hospital since his surgery with youkai and peter thromboembolic complications in the past as well.
But this was this was a complicated patient, as I say, who had previous thoracic surgery.
And unfortunately, there were delays in decisions about what to do with this big effusion about how they were going to drain it because of course,
he was anticoagulated. But what no one did was think, well, we should involve the thoracic surgeons that took his lobe out and say,
you know, can you give us some advice here? How do we how do we do this safely?
And of course, then there's a delay and confusion about, do we stop the prophylaxis, do we restart it?
Do we stop it? And he ends up with a. So I don't want to go into this in too much detail.
Suffice it to say that the findings of the internal report focussed only on the fact that
the anticoagulation was withheld inappropriately and it wasn't restarted appropriately.
And of course, that that was a problem. But what it didn't explore was all the other things that you can see in the
external report around systems problems around communication between teams.
About supporting each other and other EPR interface issues that were that were a problem.
And when you look at the recommendations, I mean,
to speak a little bit about recommendations as well and how we design those two things which really just revolved around prescribing.
Whereas on the external size, you're looking at thinking about the system and the pathway.
Thinking about joined up working patterns. And and obviously a bit about the system and process of prescribing, but perhaps in a little more detail.
So this next story is of a complicated pregnancy.
A woman in her first pregnancy who comes into the labour ward and she has premature rupture of membranes.
She's had multiple problems in the pregnancy, including intrauterine growth retardation, severe nausea and vomiting.
She got Group B strep and it's breech. So you know, this is problematic.
And unfortunately, the outcome was a premature delivery by caesarean section and the child did not survive.
So when we think about the findings from this incident and we look at what's happened again, I don't really want you to read all of the words here.
I'm just saying, look at the difference between the amount and the type of findings.
So there's a lot more around system and so forth in the external report.
But just look at the number of times that a finger is pointed at the junior midwife.
On the internal side goes back to exactly what I was saying about this paradigm shift, not who did this, but how did it happen?
And then when you think about recommendations, again, more on the internals on the external side, about missed opportunities,
about pathways, procedures and processes and so forth, and some some idea about what kind of training is good.
Let's understand what the training is, and let's devise a package that's far more productive.
And on the internal side, you'll say you'll say, let's have two meetings, a couple of lectures in a reflective account.
Thank you very much. Tickety boo. Bobbins never going to work.
So I hope it's clear the difference is when you use a far more holistic approach to thinking about these kind of serious incidents.
So the sort of feedback we got was obviously strongly positive.
What we discovered was a lot of support was needed from us in the PSA to help people come to these sorts of conclusions.
But we saw richer reports and also recognised that actually the clinical expertise
on the local site and from the investigation team is also very important.
So just having that little bit of contextual knowledge is vital.
But inertia remains a major problem. The logistics were an issue.
And of course, if we're going to do this, it will require resource and you all know about the workforce issues in the NHS at the moment.
So next steps, we obviously want to take this further,
and the long term vision is that we would work with each step and other groups to develop a national network of people with
these kind of skills that would be able to support their regions in the delivery of higher quality investigations and,
most importantly, recommendations for serious incidents.
So I'm now going to think about recommendations and focus just on one area and that checklist, right?
Cognitive aids. Checklist is a form of cognitive aid.
When you think about recommendations, this is from the Canadian framework, for instance, analysis, which is it's a really good document.
It's free to download if you're interested, it's and it's on the.
The way you can categorise and we can think about them is, you know, how likely is it that this is going to make a difference?
And you can see the sorts of things, the strong things, redesign of equipment,
all these sorts of physical interventions to try and prevent things happening a far
more powerful than procedural interventions than telling people how to do it better.
It's far better to provide them with something that will help them to do it better than to say, just think a bit harder or be more careful.
OK. I have a little bit of a problem with training being weak, I'm very passionate proponent of high quality education,
and I think the problem with training is exactly what you saw in the previous incident.
Give them a lecture. Tell them to write a reflective report by the boom by typing.
Rubbish. It needs to be low dose, high frequency interventions, particularly in the kind of environments we work in.
So the sorts of team training that I'm talking about mean we stop for an hour,
you know, or the list goes down in the afternoon, let's run an anaphylaxis. Let's run our malignant hypothermia, blah blah blah.
A massive haemorrhage, whatever. It's got to be that kind of style, but it's challenging time wise.
So those are the way we think about recommendations, but then of course, you do have to consider cost, OK?
So you've got your week and you strong, but then you think, Well, how expensive is it?
So just to give you an example of what I mean by that, obviously,
I would like to rebuild cities and fix some of the problems we face, certainly in the John Ratcliffe.
But that's prohibitively expensive. Whereas you look at give a lecture, great, that's dead cheap.
But as again, I say rubbish, I'm not going to work.
OK. So the evidence for checklists, particularly in the areas we work in, theatres and procedural environments, is very clear.
They are useful cognitive aids, but of course you have to believe in them and you have to use them properly.
And, you know, over the years, it has become apparent that where it is done properly,
where they are co-designed by the teams that are going to use them so that they are fit for purpose.
Well, they absolutely. Work for the contextual environment in which they're being used.
Great. And I think this this latest review from the Bee Gees is a really nice read, if you want the kind of two page overview of why they work.
Just go to that. It's, of course, in 2015, this document came out that steps.
Crikey, I think, Alison, I've been blinking dreaming about these, just so the mantra is standardised harmonise, educate.
OK. The standardised thing is really important.
I'm a little bit frankly bemused by the fact that we have nuts, chips, but then they said, Right, so we're a national health service.
Ideally, the way I take off a lesion in Oxford should be the way they take off a lesion in Dundee.
OK. Why would it be different? Why would the procedure be different nuances? But why would the procedure be different?
So why do I therefore need Loch Lips, local safe surgery and invasive procedures guidance?
Why? You know, correct me if I'm wrong, but there you go.
I'm so but, but it is what it is.
So just to go back to the point of this issue, this surgical issue in dermatology, the culture was fascinating around the use of the WHO checklist.
They call themselves dermatological surgeons, which again interested me and then who checklist was to sort of two little questions
like this on a box with tiny little tick boxes that they may or may not bother with.
And the doctor just did that with the patient. Absolutely against the culture that we have in theatres around the use of the show, just interesting.
Because of the way they work, the patterns of work systems and processes are all very different in dermatology,
but they're doing the same things that my colleagues in plastic surgery do on a daily basis in the West Wing.
So why is it so different over that? Interesting. There are lots of reasons, obviously, but anyway, they are amazing.
They have totally bought into this.
They've designed their checklist again, I would argue, you know, should look a bit more like the generic, but these are first steps.
What you don't want to do is put people off and say, Well, no, you can't do it like that. It must be like, this is how we do it in theatres.
You know, that's not helpful. If you're going to enact a cultural change, you must get buy in.
And so they've designed this and we use simulation to support them in embedding it.
And they recognised actually that the question they were asking about antibiotics, which they don't use that often.
But when they do, obviously they need to ask about it early. They need to say, we're going to get these in if they're going to be effective.
And they were asking the question just at night, asking if you like, OK, that's not going to work.
You need to bring that into the into the briefing. And they didn't do a morning briefing like we all do.
It was none of that. Let me just crack on fascinating.
But as I say, they're fantastic. They are a brilliant team.
All 57 of the staff that were available that work in outpatients came to the simulation session that we ran.
Then there's our area of practise stop before you block.
A standard operating procedure, when used appropriately, can support safe practise for me in delivering the blocks that I do.
It's not. Nothing is ever going to be perfect. This isn't Bullet-Proof. But it is designed to support me.
And then our surgical checklist, so we've been working in the safe surgery and Invasive Procedures Group for it's been since about 2017,
but Alison, I began just about a year ago and this was this was our surgical safety checklist, but there were issues with its design.
It had been out since 2013 and it was time for a revision.
So what happened was before we became involved in the group, kind of working group was set up to consider what needed to happen next.
And it was it was a very multi-disciplinary group, entirely appropriately, but there was no human factors input.
And so what they came up with was this. A two page document.
Admittedly, designed for EPR use, primarily, although it would have been paper based at first,
but if I looked at that in cities, you know, on a Monday morning, are we asking all these questions for complete waste of time?
Why is that relevant to what I'm doing in foot and ankle surgery or in max fax nonsense?
So we spent a long time rethinking reworking, and we had an enormous amount of support, probably from many of you in this room,
actually just looking at Ali and a number of others, all of you provided input and guidance on what this should look like.
We know it's not perfect. You know, we tested it in Max Vax Daljit and I worked together on a Tuesday and we tested it a couple of places.
She was very good about it and we tested it and mucked about with it.
And we had some really good input from the team in Max Sparks great input from the gang in orthopaedics.
And then Alister over at the Churchill.
And then lots of information from groups that provided responses to the survey monkey questionnaire that we sent out.
So this is where we're at.
Of course, it's going to be electronic soon, which, as I say, should make this process of iteration far, far more straightforward.
But the key here is we need to standardise people.
Neighbours need to walk from theatre systems that we so I recognise this. I know how to use this, I know how we do.
This co-design is vital. There's no point me imagining how they work in church offices.
You know, I've never done any of the robotic surgery that happens over there. So I suspect there are things that may be important.
Co-design is vital. Get the team that does the work to say, Yeah, that's really not important for us.
We need it to look like this buy-in at all levels top down, bottom up.
There's got to be support time given to people to do this kind of thing, and less is more.
Don't ask too many questions. And then once you've got a checklist, you need to train people how to use it.
It is not intuitive. Most checklists are read.
Do some read, confirm if you're using them as an isolated practitioner, but most of them reduce it to people.
Now in theatres, it's more than that, obviously, but that's the aviation model.
So not a static in 2018, we released a quick reference handbook, which was developed by Tim Cook and a group of Agabi, they've done a fantastic job.
This is what they look like. So they've worked with groups Ariadne Labs, such as LaGuardia's Group that have done so much work in checklists.
And this is the way the checklist and the cure now look, and it's based in with a lot of human factors to support it.
Arguably, it's still not perfect, so I'll tell you why. It's why it's not perfect, but it it's quite it's quite busy looking after you, arguably.
But many of these checklists, so for example, this one's tachycardia.
It's usually the case that you'll have a patient with a protracted tachycardia and you've got time.
So they're not losing their blood pressure, you're concerned, but you've got time, so you've got time to go through this with a colleague, right?
Let's just think now what am I missing? These are not designed to remove your clinical autonomy.
OK? They're designed to support you to release your frontal lobes, to think what's going on?
Do I need someone else here? Just let me breathe for a second. Let's let's go through the basics and know that we haven't missed anything before.
We have to start thinking about the really clever. That's just an example of circulatory bliss.
And then we thought in the group when we got a little bit of funding from actually,
well, it's all very well for us in secondary care what's happening in primary care?
I had a colleague that came to me and said, you know,
I'd really appreciate some support training teams in primary care because we're seeing a lot more emergencies.
And so we thought, well, what does it look like out there and in and our very, you know, arguably back of a [INAUDIBLE] packet order?
We found that 74 out of 76 jeeps had in the past year dealt with an emergency presentation.
They all felt anecdotally that this had been going up and it interested me when I said, Watch your data, where's your baseline?
They said, Well, we don't know.
Because they don't have the same kind of records around admission that we do, they don't admit patients, so they never give you a diagnosis.
You never know what's going on. They described a total of 301 emergencies, and the most common categories were accepted in acute asthma.
So we thought, Well, let's start to design some checklists based in good human factors practise use a Delphi process of
appropriate subject matter expertise and think about how we might support them in implementing them.
Don't just go out there and do a little bit of simulation training and think, Right, take that's done.
That'll sort them. No, that won't solve them. We need to leave them something to help them.
So we've designed a few now. This is an example of the one that's the most common emergency acute coronary syndrome.
So you can see someone is reading the list of statements down the left hand side where it's a start and then the boxes are colour coded,
according to whether it relates to drug doses.
So what what do you do if there's a critical change and then equipment and other instructions around particular circumstances?
And then the purple boxes are usually about other relevant information that you may wish to turn to.
So it's the left side that you go down, and that's what you need to train people.
And that's what we did. And it was fascinating, actually. So we run a number of scenarios.
Acute bronchiolitis was another one that they said they were all very, very frightened of.
And of course, at this time of year, it's happening very commonly. And so we set up some simulation training,
but we encourage them to use the checklist and we showed them how because many of them pick them up and started to read the orange box and said,
Already, what's that all about? Oh, I see. Oh no, I need to start over here.
And of course, there I was drawn to the colour. So arguably and I've spoken to colleagues with a specific interest in this area.
The colour could be an issue. We need to think about that a bit more.
But anyway, it's this is the start of the process and what we're hoping to do is develop a quick reference handbook along similar lines.
And arguably we should have a quick reference handbook for in-theater emergencies.
I'm sure we can all think of the sorts of things we would like people to run down, you know, if we had a maxillary artery rupture.
Oh, right, what do we do? Bang, bang, bang, that kind of thing to support people in safe practise.
So in summary. We definitely need to improve the way that we investigate incidents in health care.
I look at some of the recommendations I did. I did a review of the serious incidents that happened in 15 16 in this trust,
and the recommendations were very much along the lines of send them on that course.
Give him a lecture. Have a meeting and tell everybody not to do that again.
It's just not where we need to be. I think.
There's evidence, at least a signal that implementation of external review can support that process,
but we really need to train people around the region and nationally in how we do this.
And Peter and others both spoken around the country on this subject. And so many people are saying, You know, what's this all about?
Can you help us through this? Clearly a need that needs to be time for investing.
How many of you investigate incidents? I mean, the do. I was just thinking about the last never event that I did.
It took about 60 hours by the time I'd seen everybody written the interview transcripts.
I remember the very first one I did I and I still I feel very bad about this, but there was just no way around it.
And in fact, the person in question that I was hoping to see was a scrub nurse and we were both on call.
And I was in the hospital at four o'clock in the morning and I thought, I think he's on over in the West Wing, I'm going to ring him.
And I knew he was desperate to see me, and I knew that if we left it, I would be it would be another week.
So I rang and I said, Look, I know this is a bit weird, but we're both in the hospital. Should we at least have a conversation?
We're looking for you. Like, seriously, I'm sure we could do better than them.
So. Checklist in.
The evidence for the use, the the team effort, the belief in checklists that are properly designed and fit for purpose is very clear.
But the way we're implementing them is still substandard, and we could do an awful lot better.
And as an anaesthetist, I work in a lot of different theatre environments. You know, when I have a flexi session, I'll be sent pretty much anywhere.
And it's fascinating to me to look at the culture.
We do quite a lot of ethnography in the group, and I sometimes sit there with my ethnographers hat on thinking, OK, that was interesting.
And we are actually using ethnography in some of the areas where these incidents has happened.
To support teams in understanding what's going on in their culture and dermatology are a prime example of that.
They are super keen, really determined that they're going to improve their their use of checklists and their safe practise.
So thank you very much for your attention.
I need to say thank you, particularly to the lady with the pink ring round, which she'll hate if she's in the room.
But Janet is unfortunately leaving us super grateful for everything she's done to support Patient Safety Academy and, of course, to my colleagues.
I've got that picture off the internet Astrofisica in space.
They're fantastic. And to all of the people that have been involved in supporting the delivery of locks, Zipes, thank you.
But do please keep working on them? We we really need to get this right.
Right, right.