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									Humans Err: We’re Made That
            Way
Understanding and overcoming barriers to physician
  involvement in Patient Safety and Teamwork
                   Initiatives


              Robert J. McQuillan, MD
           Associate Professor and Chair
          Department of Anesthesiology
        Creighton University Medical Center
Overview of …

   …the multiple ways in which humans can
    contribute to the breakdown of complex,
    well-defined technologies.
   …how these various contributions may
    combine within a generic model of
    accident causation.
   …the practical implications of such
    models for the safety of healthcare.
Objectives of the session:

   To review the extent and nature of
    medical error.
   To examine promising innovations in
    patient safety.
   To consider organizational obstacles to
    change and opportunities for reducing
    errors.
Outline of Presentation

                   Relevance
                   Epidemiology
                   Physiology
                   Diagnosis
                   Treatment
USS Vincennes - Persian Gulf
1987
    Radar system indicates
     approaching aircraft;
     unable to determine
     whether descending or
     climbing.
    Poor communication;
     Situation and short
     decision time
    Incorrect determination
     that the aircraft is
     descending leads to
     decision to shoot down an
     Iranian passenger airline
     which had been climbing.
“Man – a creature made at the end of the
       week, when God was tired.”

              Mark Twain
  Physiology I


    Humans err.
We’re made that way.
Three Mile Island
The human contribution

   The contribution of       Likely explanation:
    human error to                More reliable
    accidents and                  technology
    hazardous                     Realization by
    technologies                   investigators of the
                                   importance of “latent
    increased 4x between           errors”
    1960 and 1990.
The human contribution

   “Human rather than technical failures
    now represent the greatest threat to
    complex and potentially hazardous
    systems. This includes healthcare
    systems”.
                        James T. Reason
Physiology of Human Error:
cognitive psychology
   Errors:
       Skill-based  “slips”.
       Rule and knowledge-based  “mistakes”.
   Mechanisms of error vary with the level
   Although all three levels may function
    simultaneously, with increasing expertise the
    primary focus of control moves from level 3
    toward level 1.
Critical point:

   Humans err - We’re made that way

“Man – a creature made at the end of the
       week, when God was tired.”

                Mark Twain
Active vs. latent human
failures
   Active: unsafe acts at the “sharp end” of the
    system. Often have immediate adverse
    consequences.
   Latent: result from decisions at the higher
    echelons of organizations; may lie dormant for
    long periods of time, becoming evident when
    they combine with triggering factors leading to
    adverse consequences.
Latent errors

   Understaffing
   High workload
   Poor human equipment interfaces
   Poor maintenance of equipment
   Poor management/leadership
   Poor preparation
   “Go fever” or “emergency syndrome”
       Physiology II


“The wine is spoilt and the vessel
              leaks”

    (Formula for errors:
Human frailty and bad systems)
Physiology of errors: Why is
the error rate in the practice
of medicine so high?
   Lack of awareness of the problem.
       Medical errors are generally not reported in the newspapers like
        jumbo-jet crashes and occur one at a time in 5,000 different
        locations
       Although error rates are high, serious injuries are not part of the
        daily experience of physicians and nurses but rather are perceived
        as isolated and unusual events.
   Most errors do no harm.
       Either they are intercepted or the patient’s own defenses prevent
        injury.
Physiology of errors: Why is
the error rate in the practice
of medicine so high?
   Many experts believe the most important reason
    lies within the culture of medical practice itself:

The difficulty of dealing with the reality of human
                         error.
Physiology of Errors:
Medical culture
   Goal: Error-free practice.
   Mistakes are unacceptable.
   Physicians are infallible.
   An error is a failure of character.
   Result: All errors involve negligence.
   Malpractice threat: incentive against
    disclosure/investigation of mistakes
“We see the horror of our own mistakes,
  yet we are given no permission to deal
      with their enormous emotional
  impact…The medical profession simply
      has no place for its mistakes.”
                David Hilfiker, MD
       Facing Our Mistakes. NEJM. 1984; 310:118
            (Author of “Healing the Wounds”)
Medical approach to error
prevention
   Perfectibility model: if properly trained
    and motivated, then we’ll make no
    mistakes.
   Methods used: training and punishment.
   The “reactive” model.
Medical approach to error
prevention: training
   Nursing: strict adherence to rules and
    protocols
   Medicine: emphasis less on rules and
    more on knowledge
Medical approach to error
prevention: punishment
   Social opprobrium.
   Peer disapproval.
   Blame: errors are regarded as
    someone’s fault, caused by a lack of
    sufficient attention or, worse, lack of
    caring enough to make sure you are
    correct in your action.
Medical approach to error
prevention: reactive
   Errors are discovered only when there is
    an incident – an untoward effect or injury
    to the patient.
Systems

   Performance is a
    property of a system.
   Stable system =
    predictable
    performance.
Systems

  Every system is
 perfectly designed to
  achieve exactly the
    results it gets.
Vans and Ferraris


   What’s the difference
    between a Town and
    Country van and a
    Ferrari?

								
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