ETHICAL REFLECTIONS ON ERROR: in defense of a new approach N. Yasemin YALIM, MD. PhD Professor of...
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Transcript of ETHICAL REFLECTIONS ON ERROR: in defense of a new approach N. Yasemin YALIM, MD. PhD Professor of...
ETHICAL REFLECTIONS ON ERROR: in defense of a new approach
N. Yasemin YALIM, MD. PhD
Professor of Bioethics
Ankara University School of Medicine
AGENDA
Malpractice
Errors in general
Seven myths about error
The benign face of the human factor
Real world decision making
Different approaches to error
04/18/232 Prof. Dr. Neyyire Yasemin YALIM
MALPRACTICE
is defined as a professionals lack of
knowledge, lack of experience, or
negligence that causes harm or leads to a
mistake.
04/18/233 Prof. Dr. Neyyire Yasemin YALIM
ERROR
is a failure of a planned action to be
completed as intended or the use of a
wrong plan to achieve an aim.
04/18/234 Prof. Dr. Neyyire Yasemin YALIM
ERRORS
Failure of conforming a planned action standard for the situation
Lack of necessary skills
Lack of knowledge
Negligence
Psychological factors about the performer
Significant uncertainty
Lack of on-site safety regulations
Lack of standards
04/18/235 Prof. Dr. Neyyire Yasemin YALIM
HOW HAZARDOUS?! Dangerous Regulated Ultra-safe
Health Care
Driving Scheduled Mountain Chartered Airlines Climbing Flights European
Railroads Bungee
Jumping Chemical Manufacturing
Nuclear Power
Tota
l liv
es lo
st p
er y
ear
1
1
10
10
100
100 1,000
1,000
10,000
10,000
100,000
100,000
1,000,000 10,000,000
Number of encounters for each fatality
(>1/1000) (>1/100K)
04/18/236 Prof. Dr. Neyyire Yasemin YALIM
Organizations, Institutions,
Policies, Procedures
Resources & Constraints
Practitioner
Monitored Process
BLUNT END
SHARP ENDExpertise
ActionsErro
rs
Results
Practitioners work at the sharp-end of the system. The blunt end of the system generates resources, constraints and conflicts that shape the world of technical work and produce latent failures.
04/18/237 Prof. Dr. Neyyire Yasemin YALIM
SEVEN ERROR MYTHS
Errors are intrinsically bad
Bad people make bad errors
Errors are random and variable
Practice makes perfect
Errors of professionals are rare
But they are sufficient to cause harm
Easier to change people than situations
04/18/238 Prof. Dr. Neyyire Yasemin YALIM
ABOUT MYTHS
All myths contain a grain of truths.
But the myths to be discussed here arise largely form the emotional baggage that people carry around in their everyday lives.
They present serious impediments to effective error management.
04/18/239 Prof. Dr. Neyyire Yasemin YALIM
ERRORS ARE INTRINSICALLY BAD
They are essential for coping with novel situations: trial-and-error learning
They are the debit side of a mental ‘balance sheet’ that stands very much in credit: but each ‘asset’ carries a penalty.
04/18/2310 Prof. Dr. Neyyire Yasemin YALIM
UNDER-SPECIFICATION
Errors arise when mental processes necessary for correct performance are under-specified.
Under-specification takes many forms : inattention, incomplete knowledge, sparse sensory data, forgetting, etc.
When processes are under-specified, the mind ‘defaults’ to a response that is frequent, familiar and appropriate for the context. This is very adaptive.
04/18/2311 Prof. Dr. Neyyire Yasemin YALIM
BAD ERRORS, BAD PEOPLE
Often it is the best people that make the worst errors.
About %90 of errors are culpable.
But some people knowingly adopt behaviors more likely to produce error: substance abuse, excessively long working hours.
04/18/2312 Prof. Dr. Neyyire Yasemin YALIM
ERRORS ARE NEITHER RANDOM NOR PARTICULARLY VARIABLE
Errors happen when…
You know what you are doing, but the action don’t go as planned (slips, lapses, fumbles)
You think you know what you are doing, but fail to notice contra-indications, apply a bad ‘rule’ or fail to apply a good ‘rule’ (rule-based mistakes and/or violations)
You are not really sure what you are doing (knowledge-based mistakes in novel situations)
04/18/2313 Prof. Dr. Neyyire Yasemin YALIM
PRACTICE MAKES PERFECT
Practice does not make perfect, but it alters the type of error.
Knowledge based errors decrease due to the increasing level of proficiency, while skill based errors increase.
04/18/2314 Prof. Dr. Neyyire Yasemin YALIM
THREE PERFORMANCE LEVELS
Situations
Routine
Trained for problems
Novel problems
Cognitive control modes Conscious Mixed Automatic
Skill-based
Rule-based
Knowledge- based
04/18/2315 Prof. Dr. Neyyire Yasemin YALIM
PRACTICE ALTERS THE ERROR TYPE
Knowledge-based
Rule-based
Skill-based
04/18/2316 Prof. Dr. Neyyire Yasemin YALIM
ERRORS OF PROFESSIONALS ARE RARE, BUT THEY ARE SUFFICIENT TO CAUSE HARM
Errors are rare but sufficient to cause accidents. Assumption: well-trained operators with good procedures should not make errors.
Errors are commonplace and only very occasionally necessary to complete an accident sequence that usually has a long history.
04/18/2317 Prof. Dr. Neyyire Yasemin YALIM
Complex systems fail because of the combination of multiple small failures, each individually insufficient to cause an accident. These failures are latent in the system and their pattern changes over time.
“Normal” operations
TRIGGERS
DEFENSES
LATENT FAILURES
ACCIDENT
04/18/2318 Prof. Dr. Neyyire Yasemin YALIM
NEAR MİSSES
EASIER TO CHANGE PEOPLE THAN SITUATIONS
Two ways of looking at the human contribution
The PERSON approach: Focuses on the errors and violations of individuals. Remedial efforts directed at people at ‘sharp end’.
The SYSTEM approach: Traces the causal factors back into the system as a whole. Remedial efforts directed at situations and organisations.
04/18/2319 Prof. Dr. Neyyire Yasemin YALIM
MANAGING THE MANAGEABLE
Fallibility is part of the human condition.
We are not going to change the human condition.
But we can change the conditions under which people work.
04/18/2320 Prof. Dr. Neyyire Yasemin YALIM
HUMAN VARIABILITY
Human as Human as
hazard hero
- Slips - Adjustment
- Lapses - Compensations
- Mistakes - Recoveries
- Violations - Improvisations
04/18/2321 Prof. Dr. Neyyire Yasemin YALIM
THE VARIABILITY PARADOX
Errors are implicated in some % 70-80 of accidents.
Elimination of human error is seen as a primary goal by many system managers.
As with technical unreliability, the strive for greater consistency of human action.
But human variability protects the system in a dynamic uncertain world.
04/18/2322 Prof. Dr. Neyyire Yasemin YALIM
REAL WORLD DECISION - MAKING
Put your head in the
data stream
Look out
a familiar pattern
Monitor progress of action
Generate a possible solution
04/18/2323 Prof. Dr. Neyyire Yasemin YALIM
FEATURES OF REAL WORLD DECISION - MAKING TASKS IN ENGINEERING
Ill-structured problems
Uncertain dynamic environments
Shifting, ill-defined or competing goals
Time stress
High stakes
Multiple players
Organizational goals and norms
04/18/2324 Prof. Dr. Neyyire Yasemin YALIM
CLASSICAL (LABORATORY) DECISION - MAKING MODEL
A
I’ll go for option B
04/18/2325 Prof. Dr. Neyyire Yasemin YALIM
After the
accidentBefore the
Accident
Post-accident reviews identify human error as the ‘cause’ of failure because of hindsight bias. Outcome knowledge makes the path to failure seem to have been foreseeable – although it was not foreseen.
Hindsight Bias
04/18/2326 Prof. Dr. Neyyire Yasemin YALIM
PENALTIES OF BLAMING INDIVIDUALS
Failure to discover latent conditions
Failure to identify error traps
Psychological precursors of error (inattention, forgetfulness, etc.) are the last least manageable contributors
A blame culture and a reporting culture cannot co-exist
04/18/2327 Prof. Dr. Neyyire Yasemin YALIM
A SELF-PERPETUATING CYCLE
Blame
Pursuit of ‘excellence’ Denial
04/18/2328 Prof. Dr. Neyyire Yasemin YALIM
AN EXAMPLE FOR THE DIFFERENCES BETWEEN A BLAME CULTURE AND A REPORT CULTURE
Nurse All-at-Once was fixing the leaking oxygen mask when the orderly came back with the bottle. She pointed at the chloride bottle, so he pour the chemical in it and left.
Cyanide gallon in front of the shelf and its label is semi-readable because of a leak from the ceiling.
Like this “C.a.ide”
New orderly thought that it is the chloride gallon.
Dr. Wrong-Doer pull some chloride from the bottle and injected it to Mr. Unlucky.
04/18/2329 Prof. Dr. Neyyire Yasemin YALIM
It is not the end of the story …
Create precautions:Like special notices saying that“Are you sure it is safe?”
You can still do something!!!!!?????
04/18/2330 Prof. Dr. Neyyire Yasemin YALIM
NEW PRECAUTIONS CAN BE DAMAGED …
04/18/2331 Prof. Dr. Neyyire Yasemin YALIM
WHO IS S(HE) ???
Long working periods under stress factors.
Inadequate resting periods
Continuous heavy working load
Accumulation of minor events.
04/18/2332 Prof. Dr. Neyyire Yasemin YALIM
The PERSON Approach - A
Operation room staff found out that they mixed the chemicals.
They decided to cover up the situation because all found themselves guilty.
They informed the family that Mr. Unlucky could not make it this time.
No one realized the situation.
They rewrote the tags and had the ceiling repaired next week.
04/18/2333 Prof. Dr. Neyyire Yasemin YALIM
The PERSON Approach - B
Hospital Committee for Malpractice questioned Dr. Wrong-Doer for injecting cyanide to the patient.
They concluded that any careful physician would smell the odor special to cyanide when he/she opened the bottle.
The doctor found guilty for being negligent
He was expelled from the hospital.
The hospital and the malpractice insurance of the physician paid a couple of million dollars to the family.
04/18/2334 Prof. Dr. Neyyire Yasemin YALIM
The PERSON Approach – B
Nurse blamed the orderly for his negligence, but as he never showed up at work again.
The leak on the ceiling was repaired after a number of near misses and two serious accidents.
04/18/2335 Prof. Dr. Neyyire Yasemin YALIM
The SYSTEM Approach
The Hospital Patient Safety and Medical Error Committee learned the situation when Nurse All-at-Once reported the event to them.
The safety team at the operation room traced the evidences and found out the sequence of events that caused the accident.
The Hospital Management gave an apology to the family, they went on an agreement for compensation and both the hospital and the physician’s insurance paid the compensation.
04/18/2336 Prof. Dr. Neyyire Yasemin YALIM
The SYSTEM Approach
The leak was repaired, the tags were renewed.
The safety inspector decided to add an inert colorful chemical to the poisonous chemicals; they divided storages for daily used chemicals and rarely used chemicals etc.
04/18/2337 Prof. Dr. Neyyire Yasemin YALIM
INAPPROPRIATE REACTIONS TOWARDS MALPRACTICE
Organizational reactions to failure focus on human error.
The reactions to failure are; blame and train sanctions new regulations and rules technology
Result is increased complexity and new forms of failure.
04/18/2338 Prof. Dr. Neyyire Yasemin YALIM
SOME PHILOSOPHICAL UNDERPINNINGS
The aim is to reduce harm not errors.
Cooperation across professional roles are essential.
Use prevention – identification – mitigation as principles.
Individual providers, managers, and executives have an obligation to continually work to make the system safer in return for a blame free working environment.
Progress on safety will require a synergy between methods of reliability and safety with professional knowledge and practice.
04/18/2339 Prof. Dr. Neyyire Yasemin YALIM
Every system is perfectly designed to achieve exactly the result it gets.
04/18/2340 Prof. Dr. Neyyire Yasemin YALIM
04/18/23Prof. Dr. Neyyire Yasemin YALIM41