Patient Safety--Human Factors

“Curmudge, everything we’ve talked about in the past two months has to do with human factors in patient safety. You do remember, don’t you?”

“Of course. But today ‘human factors’ is just a euphemism for, ‘No one is perfect, but some people are less perfect than others.’”

“A euphe…what? Well it does sound nicer than, ‘Some people mess up.’”

“Okay, Jaded Julie, let’s start with the ‘no one is perfect’ premise. Can you balance on just one foot?”

“(I guess I’d better humor the old guy.) Yes, but for only 10 or 20 seconds.”

“My next question would be, ‘Why not all day?’, but I already know the answer. Perfection is transient; you get tired and distracted; and you are demonstrating necessary fallibility (1). Humans are not infallible. That’s why we can’t say, despite our best efforts, that there will never be another medical error. Of course we must make those best efforts so that the inevitable errors are few and far between.”

“What about diagnoses, Curmudge? Everyone knows that they are not always correct. I have read that about 15% of all patients are misdiagnosed (2). Condition A is unlikely to be cured if an incorrect diagnosis suggests that it is Condition B.”

“Diagnosis is a BIG topic, Julie; it’s discussed at length in Groopman’s book referenced below. He advises patients to ask their doctor these three questions when he/she is making a diagnosis: (a) ‘What else could it be?’ (b) ‘Could two things be going on to explain my symptoms?’ (c) ‘Is there anything in my history, physical examination, laboratory findings, or other tests that seems not to fit with your working diagnosis?’”

“It seems as if the errors that occur in surgery are the ones that make headlines. Although it is rare, wrong-site surgery is hard to overlook. But even a little nick of the wrong organ can make recovery a lot more difficult. These must be caused by reasons other than necessary fallibility.”

“Right, Julie. Two other types of errors are those that are knowledge-based and those that are skill and experience-based (1). One would expect a surgeon to have the requisite knowledge, but of course he has to perform the surgery on somebody to gain skill and experience. If you are going in for surgery, ask the doc how many times he has performed the procedure. If it will be in a teaching hospital, request the attending physician; let the residents learn on someone else.”

“Teamwork must be critical in the OR. Is it?”

“Teamwork is certainly essential, but recent literature suggests that it is not the major source of surgical complications (3). ‘After surgical technique, most surgical error was caused by human factors: judgment, inattention to detail, and incomplete understanding, and not to organizational/system errors or breaks in communication.’ Fortunately, complications and mortality can be reduced by use of surgical checklists (4).”

“I don’t know about you, Curmudge, but after hearing what you said, I’m afraid to get sick.”

“As usual, Julie, you’ve got that right. Being healthy beats being sick any day. Maybe we both should go back and read Jan Garavaglia’s book that we referenced two weeks ago (5).”

Affinity’s Kaizen Curmudgeon

(1) http://www.emsresponder.com/print/Emergency--Medical-Services/Fallible-MEDICINE/1$5773
(2) Groopman, Jerome. Why Doctors Make Mistakes. AARP p.34-35 (September/October 2008). Based on Groopman’s book How Doctors Think. (Mariner, 2008)
(3) http://www.ncbi.nlm.nih.gov/pubmed/18847639
(4) http://www.mdconsult.com/das/news/body/117277367-2/mnfp/0/204709/1.html?nid=204709&elshs_ca1=enews&elshs_ca2=email&elshs_ca3=20090120&date=week&pos=&general=true&mine=true
(5) Garavaglia, Jan. How Not to Die: Surprising Lessons on Living Longer, Safer, and Healthier. (Crown Pub., 2008)