Why We Make Mistakes

Jeffrey Young, MD Senior Associate Chief Medical and Quality Officer Professor of Surgery Director, UVa Trauma Center University of Virginia Health System

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Understanding Clinical Care

• First step in understanding error • How do we carry out diagnosis and treatment?

• Where are the opportunities for safety?

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Effective Care Taxonomy Cognitive skill Effective Care Technical skill Teamwork

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Cognitive skill

• Knowing how to accurately assess the state of a patient – What data and actions are necessary to get an accurate assessment • Knowing the significance of the data reflecting the patient’s current state • Matching the patient’s state to the correct schema • Mentally testing and activating an acceptable action plan • Follow-up

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Background

• Medical education – Even problem based curriculums are not truly tactically oriented • Issue – data- analysis- action- reassessment – Differential diagnosis • Look at data and create diagnosis list based on characteristics of conditions and their relation to the data you currently have available • Then look at list and decrease number of diagnoses until you are left with one

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Tactical Assessment

• We are not trained to rapidly assess a situation, look at the key elements, discard less important inputs, create an action plan, implement it , and see if it worked • Military does this very well, as do other high risk jobs (aviation, etc.)

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Current Process

• Do a thorough history and physical examination – Chief complaint – HPI – ROS – Medications – Allergies – Physical Exam – Assessment – Plan

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Assessment/Plan

• Signs and symptoms lead to potential diagnoses – Diagnoses lead to investigation – Through investigation diagnoses are supported or discarded – You are left with your most likely diagnosis – Then you initiate a treatment plan

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Paradigms

• Definitive treatment delayed until all possibilities are entertained and evaluated • There is concern that aggressive early intervention can lead to overtreatment, incorrect therapies, or complications of medications and procedures

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Bottom Line

• Some patients have time for thoughtful evaluation • Some do not • First cause of error:

not making the above characterization of the patient correctly

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Technical Skill

• Knowing the indications for a test or procedure • Knowing how to safely carry out the action, and all possible adverse events related to that procedure • Insuring backup and help if needed • Monitoring the patient during the procedure • Correctly interpreting the results of the procedure • Following up to insure absence of adverse event

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Teamwork

• Can not carry out technical act, nor action plan without other competent individuals or processes • Need to know how to engage the care team – Advice members of goal, path to goal, alternative paths if they arise, – Framework for communication – Checklists and Time outs • CRM principles during action plan • Follow-up

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Example

•

Intern is on call and at 1AM nurse calls:

–

“ Mr. Smith who had a stent placed for a AAA today is having some belly pain and his temp spiked to 38.7C”

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Opportunity of Error

• Intern – “Well…how bad does his belly hurt?” – “He had his procedure today, I’m sure he just has some atelectasis, make sure he uses his incentive spirometer” – “Thanks for the call”

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Error

• Have we given that intern the tools to ask the right questions and do the right things?

• Have we prepared him to fail in this case or succeed?

• Would a better understanding of how people make errors improve his chances of success?

• Can we learn from other high risk industries?

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Experience and Error

• Novices – Novices (or people inexperienced in that domain) do not yet have the experience and knowledge to make correct decisions • They don’t know what can go wrong • Don’t know the cues • Don’t even know what data to look for – Thus they must depend on an overall philosophy or mindset toward events to guide their decisions – If that mindset is dangerous, bad care will result

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Experience and Error

• Experts – When you are an expert, you’ve gained the experience and knowledge to properly make decisions – You know what data is essential and what is extraneous – You can look for cues that put you down the correct path – Can we teach this? Or do you have to live it?

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Types of Errors

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Types of Errors

• Slips – Failures to properly adjust tasks that require little conscious attention to the characteristics of a new situation • Without thinking, ordering an adult dose of a med for a child – Correction • Make it difficult to do the wrong thing • Error requires more steps and positive affirmation – “Do you really really want to format C:?”

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Types of Error

• Lapses – Failures of memory that cause tasks not to be done – Common in task overload or distraction – How to avoid?

• Train in high intensity situations • Clear pre-arranged plans that require little creative thought and may not be perfect, but are SAFE • Reminders • Same corrective actions as for slips

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Errors

• Mistakes – The selection of incorrect actions by misclassifying a situation or failing to take into account all relevant factors in a decision • Evaluating for nausea and vomiting but not taking into account new onset DM as a cause • Attributing cold symptoms to the URI and not realizing degradation in cardiac function is the cause – Perfect execution of incorrect plans distinguishes this from lapses and slips

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Error Generators

• Assumptions – It must be OK or someone would say something • Generalizations – Didn’t happen last time, why should it happen this time? (translation; I got away with it last time….) – Successful folly is folly nonetheless (Jim Hurst, MD) • Pushing a bad system to the limits – Without working on making the system better

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Error Generators

• Laziness (not that common) • And number 1(‘s)!

– Too little FEAR that things can go wrong • •

“Fear does the work of reason”

– Winston Churchill • quickly and with very little warning.

Making CERTAIN that the conditions are stable or improving before moving on

– Too little FEAR that you don’t know everything

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Common Causes of Clinical Error

• Incorrect triage of problem – Problem more serious than most people realize • Insufficient

fear

of being wrong • Practitioner has not seen enough clinical situations to know all possibilities – Buggy knowledge – they fill in their knowledge gaps with generalizations • No follow-up – Almost all major disasters can be averted by simply going back and reassessing the patient

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Error Recovery

• Lack of cognitive understanding of condition or state by all practitioners (

Most common cause of adverse events I see)

– Team does not have enough experience or know enough to realize what is going on with patient • Patient in ectopic units • Specialists not available • Patient at low capability facility (don’t understand who is at risk)

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Error Prevention

• Very complex issue • Systems, education, decision making, communication • New knowledge, new techniques and procedures • Information systems

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Fear of Being Wrong

70 60 50 40 30 20 10 0 Pessimistic (percent of subjects) Algorithmic < 4 Weeks ICU >4 Weeks ICU U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

What Can We Learn From Studies of How Experts think?

• Schema (

what is the mindset you are using with this patient?)

–

You actually decide what “kind” of patient you have very rapidly (almost instantly), but you may not realize it

• Visualize care plan – In mind, can I see this patient going home the way they look now?

– Does the patient look like the typical patient who is admitted for this type of problem?

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Very few major disasters result from a single error

“Tactical catastrophes are rarely the outcome of a single poor decision. Small compromises incrementally close off options until a commander is forced into actions he would never choose freely” – Nate Fick

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Situations Where Error May be Unrecoverable Tenerife: March 27, 1977 Worst Aircraft Accident in History Factors: Inadequate technical skills of ATC Suspect plan (?) Experienced pilot (top airline pilot at KLM) Fog No ground control radar CRM Stepped on transmissions No warning system for active runway

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Diagram

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Errors

• Cognitive – Decision to take off – Decision to place both planes on runway – Decision to refuel • Technical – No ground radar – Communication equipment inadequate • Teamwork – Cockpit and control tower teams

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Tenerife

• This accident (more than any other) changed the culture of air safety –

To be honest, we have not yet had such an incident in medicine (IOM report?)

• • When people realized even the most experienced pilot could make egregious error, conclusion reached that human performance must be enhanced with safety measures

Sometimes we just do real stupid things

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Experience and Deliberate Practice

–

“

Good judgment comes from experience, and experience comes from bad judgment

“ –

“Luck is not method, and neither is hope. Hard work is.”

– Can we produce safe doctors with decreasing clinical experience?

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Decreasing Errors

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Role of “Philosophy” of your team and facility

• What is your “Philosophy of care”?

– Get as many patients seen as possible?

– Increase patient volumes by 10%?

– Insure every patient gets recommended care?

– Think of the worst thing that could be going on with the patient and rule it out?

– Save money?

– Avoid unnecessary radiation and testing?

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Philosophy

• Some philosophies may be at odds – Increase volume vs. provide safe care – If care is barely being safely provided at present volume, how can you expect higher volume will allow safe care without system changes?

• Trauma service functions with safeguards and double checks for a ICU census of 8—10 and a floor census of 10-12 – What happens when ICU census increases to 20 and floor census increases to 25??

– Do you have a contingency plan that goes into effect (like the military, police and fire do)

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

“Try Harder”

• Just telling people to “try harder” or “make less mistakes” or “take better care of the patients” rarely is an effective strategy • Most people are trying pretty hard and their output is more dependant on the system they are working in, not their effort

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Decision Making

•

Can teaching medical practitioners traditional clinical reasoning be detrimental?

• Naturalistic Decision Making – Gary Klein – Under conditions of uncertainly, time pressure, and high risk (medicine), experts do not use analytical methods.

– They use fast and “sufficient” strategies • In other words they don’t search for the “best” answer, just the first “acceptable” answer

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

How do experts make decisions?

• Look at patient and data • Fit that data into a schema they have seen before • Choose a plan based on their previous experience –

This is why inexperience is devastating

• War game the plan and its execution in their head (think about it, you really do this) • If plan simulates OK, proceed – If it doesn’t step back and form another option • Repeat as necessary

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Centrality of Diagnosis

• Diagnosis has been considered medicine’s central task, but is this best?

• Having a solid diagnosis can make treatment easier, but the lack of a diagnosis does not relieve the necessity to act • • Thus the central task of medicine may be management, not diagnosis

We should not say, “what is the diagnosis?” but “what should we do now?” (Beth Crandall)

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Approach

• Rapid assessment of patients initial presenting data (clinical and digital) • Rapid intervention of life threatening signs and symptoms – Nothing life threatening • Narrow to known condition – Mentally simulate treatment and evaluation » Proceed with plan » Follow results

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Situational Tactics

• We don’t teach this well – How to rapidly evaluate • Find most important data points • Assess in relation to other inputs – Assign priority to actions – Initiate actions – Reassess and revise • You must practice this by running through scenarios over and over again, or seeing patients with similar problems over and over again

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Common Emergency Problems

• Mental status change • Injury • Septic conditions • Cardiovascular problems • Respiratory problems • When we look at avoidable death, almost every case fits in one of these categories

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Common Threads in Safely Treating All These Problems

• ABC’s and Call Help • Protect from further injury or deterioration • Rapid exam and assessment of current state and contributing factors • Form plan – Mental war gaming • Initiate – May be harder than it sounds • Follow-up

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Performance by Sessions

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0 Initial Evaluation Secondary Evaluation Diagnosis Follow-up No Sessions 1-2 Sessions >2 Sessions Expert Total

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Errors in Trauma and Surgical Care

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Busy Nights (or Busy Units/Services)

• Tests and double checks fall through the cracks – 80 hour does not help this • Triage attention to severely ill – Leaving less sick to fend for themselves • Corrective action – Practice – Have defined algorithms that you stick to •

Don’t allow people to improvise just because they are busy

–

Its actually the worst time for them to improvise!

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Acidosis

• • • Can be insidious • Need to screen out occult hypoperfusion and you need to jump on persistently acidotic patients quickly – In elderly, persistent acidosis = non-survivor – In severe head injury, persistent acidosis = skilled nursing facility

“The labs must be wrong, ignore them” Sometimes people don’t want to face the fact the patients is heading in the wrong direction

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Inconsistent Neurosurgical Care

• A major problem • There are few aspects of care everyone agrees with (despite AANS guidelines) • Often the most junior attending (or resident) is saddled with trauma • Little synergy between Trauma and Neurosurgical services (often at odds) • Can we correct?

– Try to get areas of agreement and slowly increase their scope – Do the same thing every time

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Elderly Trauma

• Elderly patients with minimal mechanisms who do not communicate well – Triage problem – Treatment problem • High risk of respiratory failure • Difficult to get pain free • Interaction with current meds • Underlying disease • Intervention – focus on the elderly – Especially those with head injuries

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Conclusions

• To avoid error you should: – Expect problems – Think the patient is sicker than they look – Define evaluation and treatment algorithms • And make sure your people understand the reasons behind your algorithms – If they think its dumb, they wont follow it.

– “Thinking hurts the team” • In many many situations, this is true • Inexperienced people improvising often hurts the patient far more than it helps – Practice, Practice, Practice

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Some Solutions That Wont Work

• Don’t develop a “wizard” system – Where the patient are only treated correctly when the “wizard” is around.

• If your system doesn’t work with the most inexperienced, dimmest person at the bedside, then you don’t have a system

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Conclusions

• We need to learn how to handle urgent and emergent situations from vocations that deal with this all the time – Cockpit communication and checklists – Rapid military response • Planning and adaptation under intense pressure • Doing some things every single time, no matter what – Fire ground • Cross training of personnel • Backup • Chain of command • Bringing in more experienced people

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

Systems

• Can not always depend on people to make the right decision • Need to have systems that can rapidly recognize error and intervene • Need to expect that things will go wrong

(Hope is not a method)

• Need to explain why we have safety processes – If people don’t understand them, then their mind doesn’t engage

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M

U N I V E R S I T Y O F V I R G I N I A H E A L T H S Y S T E M