HUMAN FACTOR IN SURGERY

Emilio Gentile Warschauer

Roberto Tamburini

What we want to talk about

• How common is error?

• Why does error happen?

• How should we think of error?

• How should we respond?

CRM Outcomes

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How common is error?

• Harvard Medical Practice Study

• Reviewed medical charts of 30 121 patients admitted to 51 acute care hospitals in New York state in 1984

• In 3.7% an adverse event led to prolonged admission or produced disability at the time of discharge

• 69% of injuries were caused by errors

How common is medical error?

• Australian study• Investigators reviewed the medical records of 14

179 admissions to 28 hospitals in New South Wales and South Australia in 1995.

• An adverse event occurred in 16.6% of admissions, resulting in permanent disability in 13.7% of patients and death in 4.9%

• 51% of adverse events were considered to have been preventable.

How common is medical error?

• The differences between the US and Australian results may reflect different methods or different rates

• Other, smaller studies (including one from Britain) show similar orders of errors

• There are few studies from outpatients or primary care

How common is medical error?

• An evaluation of complications associated with medications among patients at 11 primary care sites in Boston.

• Of 2258 patients who had had drugs prescribed, 18% reported having had a drug related complication, such as gastrointestinal symptoms, sleep disturbance, or fatigue in the previous year.

Results of medical error

• In Australia medical error results in as many as 18 000 unnecessary deaths, and more than 50 000 patients become disabled each year.

• In the United States medical error results in at least 44 000 (and perhaps as many as 98 000) unnecessary deaths each year and 1 000 000 excess injuries.

9

ACCIDENTS

INCIDENTS

ERRORS (UNREPORTEDOCCURRENCES)

Fortunately, not all events become accidents…Fortunately, not all events become accidents…Fortunately, not all events become accidents…Fortunately, not all events become accidents…

Serious incidentSerious incident

Routine occurrenceRoutine occurrence

AccidentAccident

Statistical eventStatistical event

Significant eventSignificant event

11

1010

3030

200200

600600

Flight Safety Foundation, 2006; Adapted with permission.

……but events/occurrences can lead to incidents and accidentsbut events/occurrences can lead to incidents and accidents……but events/occurrences can lead to incidents and accidentsbut events/occurrences can lead to incidents and accidents

Types of error

• About half of the adverse events occurring among inpatients resulted from surgery.

• Next come– Complications from drug treatment– therapeutic mishaps

Types of error

• Cognitive errors--such as incorrect diagnosis or choosing the wrong medication-- more likely to have been preventable and more likely to result in permanent disability than technical errors.

How to think of error?

• An individual failing– Only the minority of cases amount from negligence

or misconduct; so it’s the “wrong” diagnosis

– It will not solve the problem--it will probably in fact make it worse because it fails to address the problem

– Doctors will hide errors

– May destroy many doctors inadvertently (the second victim)

How to think of error?

• A systems failure– This is the starting point for redesigning the

system and reducing error

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i.e. Scarso addestramento,manuali carenti.i.e. Scarso addestramento,manuali carenti.

Stress management

Which patients are most at risk?

• Those undergoing cardiothoracic surgery, vascular surgery, or neurosurgery

• Those with complex conditions

• Those in the emergency room

• Those looked after by inexperienced doctors

• Older patients

How dangerous is health care?

• Less than one death per 100 000 encounters– Nuclear power– European railroads– Scheduled airlines

• One death in less than 100 000 but more than 1000 encounters– Driving– Chemical manufacturing

• More than one death per 1000 encounters– Bungee jumping– Mountain climbing– Health care

Why do errors happen?

• All humans make errors: indeed, “the ability to make mistakes” allows human beings to function

• Most of medicine is complex and uncertain

• Most errors result from “the system”--inadequate training, long hours, ampoules that look the same, lack of checks, etc

• Healthcare has not tried to make itself safe

Medical situation

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TO ERR IS HUMAN

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How to respond? Tactics

• Reduce complexity

• Optimise information processing

– checklists, reminders, protocols

• Automate wisely

• Use constraints

• Mitigate the unwanted side effects of change

– with training, for example.

Building a safe healthcare system (from James Reason)

• Principles

• Policies

• Procedures

• Practices

Building a safe healthcare system (from James Reason)

• Principles– Safety is everybody’s business– Top management accepts setbacks and

anticipates errors– Past events are reviewed and changes

implemented

Building a safe healthcare system (from James Reason)

• Principles– After a mishap management concentrates on fixing

the system not blaming the individual– Understand that effective risk management depends

on the collection, analysis, and dissemination of data

– Top management is proactive in improving safety--seeks out error traps, eliminates error producing factors, brainstorms new scenarios of failure

Building a safe healthcare system (from James Reason)

• Policies– Safety related information has direct access to the

top– Risk management is not an oubliette– Meetings on safety are attended by staff from

many levels and departments– Messengers are rewarded not shot– Top managers create a reporting culture and a just

culture

Building a safe healthcare system (from James Reason)

• Policies– Reporting includes qualified indemnity,

confidentiality, separation of data collection from disciplinary procedures

– Disciplinary systems agree the difference between acceptable and unacceptable behaviour and involve peers

Building a safe healthcare system (from James Reason)

• Procedures– -Training in the recognition and recovery of

errors– Feedback on recurrent error patterns– An awareness that procedures cannot cover all

circumstances; on the spot training– Protocols written with those doing the job– Procedures must be intelligible, workable,

available

Building a safe healthcare system (from James Reason)

• Procedures– Clinical supervisors train their charges in the

mental as well as the technical skills necessary for safe and effective performance

Building a safe healthcare system (from James Reason)

• Practices– Rapid, useful, and intelligible feedback on

lessons learnt and actions needed– Bottom up information listened to and acted on– And when mishaps occur

• Acknowledge responsibility

• Apologise

• Convince patients and victims that lessons learned will reduce chance of recurrence

James Reason’s bottom line

• Fallibility is part of the human condition

• We can’t change the human condition

• We can change the conditions under which people work

Conclusions

• Human beings will always make errors

• Errors are common in medicine, killing tens of thousands

• We begin to know something about the epidemiology of error, but we need to know much more

• Naming, blaming and shaming have no remedial value

Conclusions

• We need to design health care systems that put safety first (First, do no harm)

• We know a lot about how to do that

• It’s a long, never ending job