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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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